Provider Demographics
NPI:1578271219
Name:CHACON, BRISA JANAE
Entity Type:Individual
Prefix:
First Name:BRISA
Middle Name:JANAE
Last Name:CHACON
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 1:416 AMALIA DR
Mailing Address - Street 2:
Mailing Address - City:HORIZON CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79928-7200
Mailing Address - Country:US
Mailing Address - Phone:915-282-2146
Mailing Address - Fax:
Practice Address - Street 1:1607 N ZARAGOZA RD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7908
Practice Address - Country:US
Practice Address - Phone:915-856-0071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-11
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist