Provider Demographics
NPI:1326137480
Name:AMADEO VALENZUELA JR
Entity Type:Organization
Organization Name:AMADEO VALENZUELA JR
Other - Org Name:FREDS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMADEO
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENZUELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-748-2141
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:RIO HONDO
Mailing Address - State:TX
Mailing Address - Zip Code:78583-0800
Mailing Address - Country:US
Mailing Address - Phone:956-748-2141
Mailing Address - Fax:956-748-2570
Practice Address - Street 1:200 W COLORADO AVE
Practice Address - Street 2:
Practice Address - City:RIO HONDO
Practice Address - State:TX
Practice Address - Zip Code:78583
Practice Address - Country:US
Practice Address - Phone:956-748-2141
Practice Address - Fax:956-748-2570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX01973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144258Medicaid