Provider Demographics
NPI:1366043283
Name:CARRILLO, JANUARY
Entity Type:Individual
Prefix:
First Name:JANUARY
Middle Name:
Last Name:CARRILLO
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 1:2300 LAFAYETTE DR
Mailing Address - Street 2:
Mailing Address - City:HEATH
Mailing Address - State:TX
Mailing Address - Zip Code:75032-7642
Mailing Address - Country:US
Mailing Address - Phone:915-256-2436
Mailing Address - Fax:
Practice Address - Street 1:12300 LAKE JUNE RD
Practice Address - Street 2:
Practice Address - City:BALCH SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75180-1636
Practice Address - Country:US
Practice Address - Phone:972-286-0180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56376183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist