Provider Demographics
NPI:1073834107
Name:GAVILAN, MANOLO D (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MANOLO
Middle Name:D
Last Name:GAVILAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5702 WEBER RD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-3965
Mailing Address - Country:US
Mailing Address - Phone:361-855-4440
Mailing Address - Fax:
Practice Address - Street 1:5702 WEBER RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-3965
Practice Address - Country:US
Practice Address - Phone:361-855-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-11
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48025183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist