Provider Demographics
NPI:1881226538
Name:DE LOS SANTOS, MARIO JESUS JR
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:JESUS
Last Name:DE LOS SANTOS
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 1:2515 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1037
Mailing Address - Country:US
Mailing Address - Phone:210-354-0101
Mailing Address - Fax:210-354-0404
Practice Address - Street 1:2515 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1037
Practice Address - Country:US
Practice Address - Phone:210-354-0101
Practice Address - Fax:210-354-0404
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19997183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist