Provider Demographics
NPI:1235294661
Name:PROFESSIONAL PAVILION PHARMACY INC
Entity Type:Organization
Organization Name:PROFESSIONAL PAVILION PHARMACY INC
Other - Org Name:PROFESSIONAL PAVILION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-271-7575
Mailing Address - Street 1:315 N SAN SABA
Mailing Address - Street 2:STE 110
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3154
Mailing Address - Country:US
Mailing Address - Phone:210-212-7455
Mailing Address - Fax:210-212-6643
Practice Address - Street 1:315 N SAN SABA
Practice Address - Street 2:STE 110
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3154
Practice Address - Country:US
Practice Address - Phone:210-212-7455
Practice Address - Fax:210-212-6643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX174173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4599950OtherNCPDP PROVIDER IDENTIFICATION NUMBER