Provider Demographics
NPI:1629678883
Name:VIDAL, RAFAEL CHRISTIAN JR
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:CHRISTIAN
Last Name:VIDAL
Suffix:JR
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 1:3186 VENESA DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-3050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:496 S BIBB AVE
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-5063
Practice Address - Country:US
Practice Address - Phone:830-773-9001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66146183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist