Provider Demographics
NPI:1679974067
Name:VALENZUELA, JUAN PABLO
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:PABLO
Last Name:VALENZUELA
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 1:70 W CAMINO RANCHO LUCIDO
Mailing Address - Street 2:
Mailing Address - City:SAHUARITA
Mailing Address - State:AZ
Mailing Address - Zip Code:85629-8971
Mailing Address - Country:US
Mailing Address - Phone:251-599-8479
Mailing Address - Fax:
Practice Address - Street 1:300 W MARIPOSA RD
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-1043
Practice Address - Country:US
Practice Address - Phone:251-599-8479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS020303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist