Provider Demographics
NPI:1629673504
Name:VELASQUEZ, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:VELASQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3034 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75041-3419
Mailing Address - Country:US
Mailing Address - Phone:972-271-3801
Mailing Address - Fax:
Practice Address - Street 1:3034 S 1ST ST
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-3419
Practice Address - Country:US
Practice Address - Phone:972-271-3801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67379183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist