Provider Demographics
NPI:1528373842
Name:MORENO, PHILLIP JAMES (RPH)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:JAMES
Last Name:MORENO
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 1:6839 SAN PEDRO
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-7202
Mailing Address - Country:US
Mailing Address - Phone:210-979-8660
Mailing Address - Fax:210-979-9078
Practice Address - Street 1:6839 SAN PEDRO
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-7202
Practice Address - Country:US
Practice Address - Phone:210-979-8660
Practice Address - Fax:210-979-9078
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist