MEDICARE: BUENA VISTA DISCOUNT PHARMACY

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	261QH0100X	Health Service Clinic/Center	11492	TX

General Provider Information

NPI Number	:	1306015177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUENA VISTA DISCOUNT PHARMACY

Provider Business Mailing Address
First Line	:	2223 BUENA VISTA ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78207-3702
Country	:	US
Telephone Number	:	210-226-3699
Fax Number	:	210-226-2130

Provider Business Practice Location Address
First Line	:	2223 BUENA VISTA ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78207-3702
Country	:	US
Telephone Number	:	210-226-3699
Fax Number	:	210-226-2130

Authorized Official
Title or Position	:	PHARMACISTS/OWNER
Name	:	MR. JESSE DE LA CRUZ
Credential	:	RPH
Telephone Number	:	210-226-3699

Provider Enumeration Date	:	02/26/2008
Last Update Date	:	07/29/2008

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