Provider Demographics
NPI:1871179259
Name:TELLEZ, EDELMIRO
Entity Type:Individual
Prefix:MR
First Name:EDELMIRO
Middle Name:
Last Name:TELLEZ
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 1:2515 CASTROVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78237-3359
Mailing Address - Country:US
Mailing Address - Phone:210-432-2361
Mailing Address - Fax:
Practice Address - Street 1:2515 CASTROVILLE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78237-3359
Practice Address - Country:US
Practice Address - Phone:210-432-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX183700000X, 3336L0003X, 3336M0003X, 3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183700000XPharmacy Service ProvidersPharmacy Technician
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy