Provider Demographics
NPI:1558381475
Name:WESLACO PHARMACY INC
Entity Type:Organization
Organization Name:WESLACO PHARMACY INC
Other - Org Name:WESLACO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:956-969-0636
Mailing Address - Street 1:1102 S AIRPORT DR
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-6652
Mailing Address - Country:US
Mailing Address - Phone:956-969-0636
Mailing Address - Fax:956-969-0611
Practice Address - Street 1:1102 S AIRPORT DR
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-6652
Practice Address - Country:US
Practice Address - Phone:956-969-0636
Practice Address - Fax:956-969-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX243773336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2090224OtherPK
6006680001Medicare NSC
4503175OtherNCPDP PROVIDER IDENTIFICATION NUMBER