Provider Demographics
NPI:1942439351
Name:QUINTANILLA, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:QUINTANILLA
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 1:8050 LINDBERGH LNDG
Mailing Address - Street 2:
Mailing Address - City:BROOKS CITY BASE
Mailing Address - State:TX
Mailing Address - Zip Code:78235-5334
Mailing Address - Country:US
Mailing Address - Phone:210-536-2134
Mailing Address - Fax:210-536-6009
Practice Address - Street 1:8050 LINDBERGH LNDG
Practice Address - Street 2:
Practice Address - City:BROOKS CITY BASE
Practice Address - State:TX
Practice Address - Zip Code:78235-5334
Practice Address - Country:US
Practice Address - Phone:210-536-2134
Practice Address - Fax:210-536-6009
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist