Provider Demographics
NPI:1033128392
Name:VALENZUELA, STEPHEN RAY
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RAY
Last Name:VALENZUELA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:TX
Mailing Address - Zip Code:79772-4719
Mailing Address - Country:US
Mailing Address - Phone:432-447-2266
Mailing Address - Fax:432-447-3909
Practice Address - Street 1:1800 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:TX
Practice Address - Zip Code:79772-4719
Practice Address - Country:US
Practice Address - Phone:432-447-2266
Practice Address - Fax:432-447-3909
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33529183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4500484Medicaid