MEDICARE: MR. VERNON THEODORE LEW RPH

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	1835N1003X	Nutrition Support Pharmacist	24525	TX

General Provider Information

NPI Number	:	1093792665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VERNON THEODORE LEW RPH

Provider Business Mailing Address
First Line	:	8 LISER GLN
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78257-1377
Country	:	US
Telephone Number	:	210-481-8442
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 BERGQUIST DR
Second Line	:	BLDG 8410
City	:	SAN ANTONIO
State	:	TX
Zip	:	78236-9907
Country	:	US
Telephone Number	:	210-292-8418
Fax Number	:	210-292-7207

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

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	09/03/2013

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