Provider Demographics
NPI:1366024663
Name:DIAZ, GABRIELLE RENEE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:RENEE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7260 PALM PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-6037
Mailing Address - Country:US
Mailing Address - Phone:210-723-8133
Mailing Address - Fax:
Practice Address - Street 1:703 E HILDEBRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2535
Practice Address - Country:US
Practice Address - Phone:210-883-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40798183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist