Provider Demographics
NPI:1922489434
Name:C DE BACA, WILLIAM SR (RPH)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:C DE BACA
Suffix:SR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 NEWT PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-1663
Mailing Address - Country:US
Mailing Address - Phone:972-642-8888
Mailing Address - Fax:972-642-9257
Practice Address - Street 1:215 N CARRIER PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-5425
Practice Address - Country:US
Practice Address - Phone:972-642-8888
Practice Address - Fax:972-642-9257
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26349183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist