Provider Demographics
NPI:1003417320
Name:JUAREZ, IVAN JORGE (PHARMD, RPH)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:JORGE
Last Name:JUAREZ
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 AVENUE A APT 1302
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1281
Mailing Address - Country:US
Mailing Address - Phone:830-591-7934
Mailing Address - Fax:
Practice Address - Street 1:819 N OAK ST
Practice Address - Street 2:
Practice Address - City:PEARSALL
Practice Address - State:TX
Practice Address - Zip Code:78061-3422
Practice Address - Country:US
Practice Address - Phone:830-591-7934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50106183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist