Provider Demographics
NPI:1841576345
Name:MARTILLO, JORGE ANTONIO (RPH)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:ANTONIO
Last Name:MARTILLO
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 1:700 HILL TRAIL DR
Mailing Address - Street 2:APT 1025
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-5686
Mailing Address - Country:US
Mailing Address - Phone:718-926-3432
Mailing Address - Fax:
Practice Address - Street 1:7151 BOULEVARD 26
Practice Address - Street 2:( WALGREENS )
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-8607
Practice Address - Country:US
Practice Address - Phone:817-514-9474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47343183500000X
NY044133183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist