Provider Demographics
NPI:1336730829
Name:DOMINGUEZ, FREDERICK RAE (CPHT)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:RAE
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 EAST FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TX
Mailing Address - Zip Code:78516
Mailing Address - Country:US
Mailing Address - Phone:956-702-7550
Mailing Address - Fax:956-702-0612
Practice Address - Street 1:1211 EAST FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:TX
Practice Address - Zip Code:78516
Practice Address - Country:US
Practice Address - Phone:956-702-7550
Practice Address - Fax:956-702-0612
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX166292183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician