Provider Demographics
NPI:1558975920
Name:PERALES, SAMANTHA JO (PHARMD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:PERALES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1082
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TX
Mailing Address - Zip Code:78516-1082
Mailing Address - Country:US
Mailing Address - Phone:956-460-3124
Mailing Address - Fax:
Practice Address - Street 1:411 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ELSA
Practice Address - State:TX
Practice Address - Zip Code:78543
Practice Address - Country:US
Practice Address - Phone:956-262-9450
Practice Address - Fax:956-262-9776
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61292183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist