MEDICARE: MR. RICARDO CISNEROS CPHT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183700000X	Pharmacy Technician	242092	TX
2	183700000X	Pharmacy Technician	500107010057077	TX

General Provider Information

NPI Number	:	1043560907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICARDO CISNEROS CPHT

Provider Business Mailing Address
First Line	:	11519 LINGO
Second Line	:
City	:	HELOTES
State	:	TX
Zip	:	78023
Country	:	US
Telephone Number	:	915-433-0765
Fax Number	:

Provider Business Practice Location Address
First Line	:	2748 WORTH RD
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-6031
Country	:	US
Telephone Number	:	210-221-6428
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2012
Last Update Date	:	06/14/2017

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