Healthcare Provider Details

I. General information

NPI: 1174921803
Provider Name (Legal Business Name): ONE SOURCE PHARMACY AND MEDICAL SUPPLIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15733 SAN PEDRO AVE
SAN ANTONIO TX
78232-3726
US

IV. Provider business mailing address

15733 SAN PEDRO AVE
SAN ANTONIO TX
78232-3726
US

V. Phone/Fax

Practice location:
  • Phone: 210-493-8378
  • Fax: 210-408-0722
Mailing address:
  • Phone: 210-493-8378
  • Fax: 210-408-0722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number29690
License Number StateTX

VIII. Authorized Official

Name: JON JIMENEZ
Title or Position: CEO
Credential:
Phone: 210-493-8378