=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194877449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIDEL G HUERTA JR INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2007
-----------------------------------------------------
Last Update Date | 01/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 818 BROOKLYN AVE STE 2 STE 2
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78215-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-228-0300
-----------------------------------------------------
Fax | 210-228-0313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 818 BROOKLYN AVE STE 2
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78215-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-228-0300
-----------------------------------------------------
Fax | 210-228-0313
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | FIDEL HUERTA
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 210-433-9991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 23802
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------