Provider Demographics
NPI:1417532789
Name:CANCHOLA, GRACIE
Entity Type:Individual
Prefix:
First Name:GRACIE
Middle Name:
Last Name:CANCHOLA
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 1:1505 E RIO GRANDE ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-7396
Mailing Address - Country:US
Mailing Address - Phone:361-572-8001
Mailing Address - Fax:361-574-9844
Practice Address - Street 1:1505 E RIO GRANDE ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-7396
Practice Address - Country:US
Practice Address - Phone:361-572-8001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician