Provider Demographics
NPI:1407526452
Name:BALDERAS, KEVIN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:BALDERAS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 HULEN PL APT 209
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7298
Mailing Address - Country:US
Mailing Address - Phone:210-332-2311
Mailing Address - Fax:
Practice Address - Street 1:4350 OAK PARK LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-1512
Practice Address - Country:US
Practice Address - Phone:817-920-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist