Provider Demographics
NPI:1073673844
Name:CASTILLO, MARTHA WALLACE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:WALLACE
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1494 VIA APPIA ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-6611
Mailing Address - Country:US
Mailing Address - Phone:915-833-8488
Mailing Address - Fax:915-532-7116
Practice Address - Street 1:1901 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5113
Practice Address - Country:US
Practice Address - Phone:915-747-4840
Practice Address - Fax:915-532-7116
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4067183500000X
TX262021835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered1835X0200XPharmacy Service ProvidersPharmacistOncology