Provider Demographics
NPI:1053630012
Name:OBIALO, THEODORE C (RPH)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:C
Last Name:OBIALO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:TED
Other - Middle Name:
Other - Last Name:OBIALO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:3820 STATE HIGHWAY 64 W
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-6924
Mailing Address - Country:US
Mailing Address - Phone:903-597-3888
Mailing Address - Fax:
Practice Address - Street 1:3820 STATE HIGHWAY 64 W
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75704-6924
Practice Address - Country:US
Practice Address - Phone:903-597-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33412183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX33412OtherPHARMACIST LICENCE