Provider Demographics
NPI:1508467903
Name:SANTOS, IVANA LORIEL
Entity Type:Individual
Prefix:
First Name:IVANA
Middle Name:LORIEL
Last Name:SANTOS
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 1:305 10TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78114-3189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 10TH ST
Practice Address - Street 2:
Practice Address - City:FLORESVILLE
Practice Address - State:TX
Practice Address - Zip Code:78114-3189
Practice Address - Country:US
Practice Address - Phone:830-393-3119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist