Provider Demographics
NPI:1134636319
Name:JACQUEZ, DAISY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DAISY
Middle Name:
Last Name:JACQUEZ
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 NNE LOOP 323
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75708-2014
Mailing Address - Country:US
Mailing Address - Phone:903-535-7200
Mailing Address - Fax:
Practice Address - Street 1:1041 NNE LOOP 323
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75708-2014
Practice Address - Country:US
Practice Address - Phone:903-535-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61895183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX61895OtherTEXAS STATE BOARD OF PHARMACY