Provider Demographics
NPI:1972967396
Name:JUAREZ, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:JUAREZ
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 1:509 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT STOCKTON
Mailing Address - State:TX
Mailing Address - Zip Code:79735-5623
Mailing Address - Country:US
Mailing Address - Phone:432-336-2297
Mailing Address - Fax:432-336-6248
Practice Address - Street 1:1501 B NORTH ERMA AVE
Practice Address - Street 2:
Practice Address - City:PRESIDIO
Practice Address - State:TX
Practice Address - Zip Code:79845
Practice Address - Country:US
Practice Address - Phone:432-229-2252
Practice Address - Fax:432-229-3152
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27914183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist