=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689165342
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GALLISSARA AGAVATPANITCH R.PH.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2018
-----------------------------------------------------
Last Update Date | 04/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7400 MERTON MINTER ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-4404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-617-5300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 76 VETERANS AVE
-----------------------------------------------------
City | BATH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14810-0810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-664-4415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 60954
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------