Provider Demographics
NPI:1679219273
Name:VASQUEZ, ELMA NOEMI
Entity Type:Individual
Prefix:
First Name:ELMA
Middle Name:NOEMI
Last Name:VASQUEZ
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 1:1101 S INTERSTATE 35
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-5400
Mailing Address - Country:US
Mailing Address - Phone:512-779-4028
Mailing Address - Fax:
Practice Address - Street 1:1101 S INTERSTATE 35
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-5400
Practice Address - Country:US
Practice Address - Phone:512-779-4028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-07
Last Update Date:2022-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX134853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist