Healthcare Provider Details

I. General information

NPI: 1528778826
Provider Name (Legal Business Name): MAYA SAMIR DATT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2022
Last Update Date: 11/29/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9255 FM 471 WEST
SAN ANTONIO TX
78250
US

IV. Provider business mailing address

9255 FM 471 WEST
SAN ANTONIO TX
78250
US

V. Phone/Fax

Practice location:
  • Phone: 210-680-2958
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number272606
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: