Provider Demographics
NPI:1376608885
Name:SAMUEL A GURROLA
Entity Type:Organization
Organization Name:SAMUEL A GURROLA
Other - Org Name:PALAFOX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GURROLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-886-3394
Mailing Address - Street 1:929 S. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:TX
Mailing Address - Zip Code:79821
Mailing Address - Country:US
Mailing Address - Phone:915-886-3394
Mailing Address - Fax:915-886-3290
Practice Address - Street 1:929 S. MAIN ST
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:TX
Practice Address - Zip Code:79821
Practice Address - Country:US
Practice Address - Phone:915-886-3394
Practice Address - Fax:915-886-3290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00056697Medicaid