Provider Demographics
NPI:1912550948
Name:PORFIRIO, ANDY (CPHT)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:PORFIRIO
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ANDY.PORFIRIO7@GMAIL.COM
Mailing Address - Street 2:14900 EAST STATE HIGHWAY 21
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77808
Mailing Address - Country:US
Mailing Address - Phone:979-450-6302
Mailing Address - Fax:
Practice Address - Street 1:14900 E STATE HIGHWAY 21
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77808-9364
Practice Address - Country:US
Practice Address - Phone:979-450-6302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX298280183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician