Healthcare Provider Details

I. General information

NPI: 1376564310
Provider Name (Legal Business Name): MARIOS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 09/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 BROADWAY ST
SAN ANTONIO TX
78215-1037
US

IV. Provider business mailing address

2501 W WILLIAM CANNON DR STE. 203
AUSTIN TX
78745-5281
US

V. Phone/Fax

Practice location:
  • Phone: 210-354-0101
  • Fax: 210-354-0404
Mailing address:
  • Phone: 512-707-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number24112
License Number StateTX

VIII. Authorized Official

Name: JESSICA RUIZ
Title or Position: CONTROLLER
Credential: RN
Phone: 210-913-2244