Provider Demographics
NPI:1407174683
Name:ROCHA, EDWARD C
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:ROCHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 VETERANS BLVD
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-4658
Mailing Address - Country:US
Mailing Address - Phone:830-774-4579
Mailing Address - Fax:
Practice Address - Street 1:200 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-4658
Practice Address - Country:US
Practice Address - Phone:830-774-4579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30538183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist