Provider Demographics
NPI:1154659456
Name:PADDACK, MISTY ANN (RPH)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:ANN
Last Name:PADDACK
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 1:19203 STONE OAK PKWY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3254
Mailing Address - Country:US
Mailing Address - Phone:210-403-0002
Mailing Address - Fax:210-403-0740
Practice Address - Street 1:19203 STONE OAK PKWY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3254
Practice Address - Country:US
Practice Address - Phone:210-403-0002
Practice Address - Fax:210-403-0740
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist