Provider Demographics
NPI:1598130072
Name:BALLAS, GINA (RPH)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BALLAS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11335 SSG SIMS STREET, EAST BLISS
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79920-5001
Mailing Address - Country:US
Mailing Address - Phone:915-742-1012
Mailing Address - Fax:
Practice Address - Street 1:11335 SSG SIMS STREET
Practice Address - Street 2:
Practice Address - City:EAST FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79920-5001
Practice Address - Country:US
Practice Address - Phone:915-742-1012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21283183500000X
RI03406183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist