=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316000912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIDEL G HUERTA JR. INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2006
-----------------------------------------------------
Last Update Date | 11/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 818 BROOKLYN AVE
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78215-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-433-5400
-----------------------------------------------------
Fax | 210-433-5450
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 818 BROOKLYN AVE
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78215-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-433-5400
-----------------------------------------------------
Fax | 210-433-5450
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. FIDEL G HUERTA JR.
-----------------------------------------------------
Credential | PHARMACIST
-----------------------------------------------------
Telephone | 210-433-9991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 23802
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 17446
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------