Provider Demographics
NPI:1629791108
Name:BERNAL, LACI ANN
Entity Type:Individual
Prefix:
First Name:LACI
Middle Name:ANN
Last Name:BERNAL
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 1:159 E COUNTY ROAD 2130
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78363-8867
Mailing Address - Country:US
Mailing Address - Phone:361-522-1715
Mailing Address - Fax:
Practice Address - Street 1:700 S SAINT MARYS ST
Practice Address - Street 2:
Practice Address - City:FALFURRIAS
Practice Address - State:TX
Practice Address - Zip Code:78355-4365
Practice Address - Country:US
Practice Address - Phone:361-325-2910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65367183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist