Provider Demographics
NPI:1710208723
Name:BALBASTRO, RUBEN CONSOLACION (RPH)
Entity Type:Individual
Prefix:
First Name:RUBEN
Middle Name:CONSOLACION
Last Name:BALBASTRO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 CAMERON VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3044
Mailing Address - Country:US
Mailing Address - Phone:336-768-6610
Mailing Address - Fax:
Practice Address - Street 1:3440 ROBINHOOD RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4702
Practice Address - Country:US
Practice Address - Phone:336-768-6610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18538183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist