Provider Demographics
NPI:1477220754
Name:REYES, ROSALIDIA
Entity Type:Individual
Prefix:
First Name:ROSALIDIA
Middle Name:
Last Name:REYES
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 1:104 N HASLER BLVD
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-3740
Mailing Address - Country:US
Mailing Address - Phone:512-581-7044
Mailing Address - Fax:512-332-0422
Practice Address - Street 1:104 N HASLER BLVD
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3740
Practice Address - Country:US
Practice Address - Phone:512-581-7044
Practice Address - Fax:512-332-0422
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX191514183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician