Provider Demographics
NPI:1205819885
Name:DAVILA PHARMACY, INC.
Entity Type:Organization
Organization Name:DAVILA PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVILA
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:210-226-5293
Mailing Address - Street 1:1423 GUADALUPE ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-5527
Mailing Address - Country:US
Mailing Address - Phone:210-226-5293
Mailing Address - Fax:210-224-9257
Practice Address - Street 1:1423 GUADALUPE ST
Practice Address - Street 2:SUITE 108
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-5527
Practice Address - Country:US
Practice Address - Phone:210-226-5293
Practice Address - Fax:210-224-9257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX01055333600000X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079060201OtherCSHCN
TX125943402Medicaid
TX125943403Medicaid
TX013612901Medicaid
TX1255943401OtherCSHCN
TX0380320001Medicare ID - Type Unspecified