Provider Demographics
NPI:1245882208
Name:MORENO, JORGE LUIS (RPH)
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LUIS
Last Name:MORENO
Suffix:
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 1:131 FM 3168
Mailing Address - Street 2:
Mailing Address - City:RAYMONDVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78580-3605
Mailing Address - Country:US
Mailing Address - Phone:956-689-5216
Mailing Address - Fax:956-689-4477
Practice Address - Street 1:131 FM 3168
Practice Address - Street 2:
Practice Address - City:RAYMONDVILLE
Practice Address - State:TX
Practice Address - Zip Code:78580-3605
Practice Address - Country:US
Practice Address - Phone:956-689-5216
Practice Address - Fax:956-689-4477
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist