Provider Demographics
NPI:1851980270
Name:DOMINGUEZ, CARRIE MARIE
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:MARIE
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 SW MILITARY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-1642
Mailing Address - Country:US
Mailing Address - Phone:210-927-6875
Mailing Address - Fax:210-922-4789
Practice Address - Street 1:735 SW MILITARY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78221-1642
Practice Address - Country:US
Practice Address - Phone:210-927-6875
Practice Address - Fax:210-922-4789
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX163676183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician