Provider Demographics
NPI:1902406184
Name:DAGO, MARCELIN L
Entity Type:Individual
Prefix:
First Name:MARCELIN
Middle Name:L
Last Name:DAGO
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 1:8030 BANDERA RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78250-5130
Mailing Address - Country:US
Mailing Address - Phone:210-520-6824
Mailing Address - Fax:210-520-6710
Practice Address - Street 1:8030 BANDERA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78250-5130
Practice Address - Country:US
Practice Address - Phone:210-520-6824
Practice Address - Fax:210-520-6710
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty