Provider Demographics
NPI:1710576889
Name:CARRILLO, GERARDO ANTONIO JR
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:ANTONIO
Last Name:CARRILLO
Suffix:JR
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 1:2310 E SAUNDERS ST
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-5435
Mailing Address - Country:US
Mailing Address - Phone:956-724-1141
Mailing Address - Fax:
Practice Address - Street 1:2310 E SAUNDERS ST
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-5435
Practice Address - Country:US
Practice Address - Phone:956-724-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX272846183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician