Provider Demographics
NPI:1497357347
Name:VILLA, LUCERO
Entity Type:Individual
Prefix:
First Name:LUCERO
Middle Name:
Last Name:VILLA
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 1:156 PRIVATE ROAD 4742
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-1084
Mailing Address - Country:US
Mailing Address - Phone:903-563-0072
Mailing Address - Fax:
Practice Address - Street 1:609 LINDA DR
Practice Address - Street 2:
Practice Address - City:DAINGERFIELD
Practice Address - State:TX
Practice Address - Zip Code:75638-2115
Practice Address - Country:US
Practice Address - Phone:903-645-4552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67603183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1841363314OtherRETAIL PHARMACY