Provider Demographics
NPI:1336454750
Name:FAT-ANTHONY, WILLIAM R
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:FAT-ANTHONY
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 1:3401 W MILE 5 RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78574-5313
Mailing Address - Country:US
Mailing Address - Phone:956-802-4664
Mailing Address - Fax:956-424-3599
Practice Address - Street 1:3401 W MILE 5 RD
Practice Address - Street 2:SUITE 2
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78574-5313
Practice Address - Country:US
Practice Address - Phone:956-802-4664
Practice Address - Fax:956-424-3599
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-10
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2206609305S00000X
TX28238332B00000X, 333600000X, 3336C0003X
TX45974183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No333600000XSuppliersPharmacyGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty