Provider Demographics
NPI:1295335347
Name:BALBOA, ANTONIO RICARDO (PHARMD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:RICARDO
Last Name:BALBOA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 S MILE 2 W
Mailing Address - Street 2:
Mailing Address - City:MERCEDES
Mailing Address - State:TX
Mailing Address - Zip Code:78570-7419
Mailing Address - Country:US
Mailing Address - Phone:956-314-3839
Mailing Address - Fax:
Practice Address - Street 1:3000 N JACKSON RD
Practice Address - Street 2:
Practice Address - City:HIDALGO
Practice Address - State:TX
Practice Address - Zip Code:78557-3882
Practice Address - Country:US
Practice Address - Phone:956-904-4829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX54414183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist