=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801330303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESIDIO PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2016
-----------------------------------------------------
Last Update Date | 01/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 B NORTH ERMA AVE
-----------------------------------------------------
City | PRESIDIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-229-2252
-----------------------------------------------------
Fax | 432-229-3152
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2044
-----------------------------------------------------
City | PRESIDIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79845-2044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-229-2252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MARIO X JUAREZ
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 432-336-2297
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 31099
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------