Provider Demographics
NPI:1003802307
Name:MEDINA, ROBERT JR (BS-RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:MEDINA
Suffix:JR
Gender:M
Credentials:BS-RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 TIFFANY LN
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-1831
Mailing Address - Country:US
Mailing Address - Phone:806-341-1018
Mailing Address - Fax:806-354-7857
Practice Address - Street 1:6010 AMARILLO BLVD WEST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106
Practice Address - Country:US
Practice Address - Phone:806-354-7898
Practice Address - Fax:806-354-7857
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35514183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist