Provider Demographics
NPI:1164053336
Name:ERVIN, DEWAYNE
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:
Last Name:ERVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3541 PALMER HWY
Mailing Address - Street 2:
Mailing Address - City:TEXAS CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77590-6513
Mailing Address - Country:US
Mailing Address - Phone:409-945-3436
Mailing Address - Fax:409-948-2636
Practice Address - Street 1:3541 PALMER HWY
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77590-6513
Practice Address - Country:US
Practice Address - Phone:409-945-3436
Practice Address - Fax:409-948-2636
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX196011835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist