Provider Demographics
NPI:1922722545
Name:RILEY, JUSTIN ANTHONY
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ANTHONY
Last Name:RILEY
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 1:409 VETERANS BLVD
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-4467
Mailing Address - Country:US
Mailing Address - Phone:830-719-5129
Mailing Address - Fax:830-775-2797
Practice Address - Street 1:409 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-4467
Practice Address - Country:US
Practice Address - Phone:830-775-8538
Practice Address - Fax:830-775-2797
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67776183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist