Provider Demographics
NPI:1679109425
Name:CARVAJAL, CHARLES EDWARD
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:CARVAJAL
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 1:3410 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214-2606
Mailing Address - Country:US
Mailing Address - Phone:210-922-2176
Mailing Address - Fax:
Practice Address - Street 1:3410 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78214-2606
Practice Address - Country:US
Practice Address - Phone:210-922-2176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist