Provider Demographics
NPI:1821862897
Name:LAVILLA, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:LAVILLA
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 1:177 NORTHSHORE BLVD APT 5013
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-1300
Mailing Address - Country:US
Mailing Address - Phone:956-534-1366
Mailing Address - Fax:
Practice Address - Street 1:2501 W WHEELER AVE
Practice Address - Street 2:
Practice Address - City:ARANSAS PASS
Practice Address - State:TX
Practice Address - Zip Code:78336-5916
Practice Address - Country:US
Practice Address - Phone:361-758-2867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX734251835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist