Provider Demographics
NPI:1457511370
Name:RESENDEZ, JUAN PABLO (RPH)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:PABLO
Last Name:RESENDEZ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 BOCA CHICA BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-8132
Mailing Address - Country:US
Mailing Address - Phone:956-550-0632
Mailing Address - Fax:956-541-4007
Practice Address - Street 1:1740 BOCA CHICA BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-8132
Practice Address - Country:US
Practice Address - Phone:956-550-0632
Practice Address - Fax:956-541-4007
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-13
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31400183500000X
332B00000X
TX168543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4596081OtherNCPDP
74-2765978OtherFEDERAL TAX ID (IRS#)
TX144372Medicaid
TX4596081OtherNCPDP