Provider Demographics
NPI:1447046289
Name:SERNA, MARITES TALAVERA
Entity type:Individual
Prefix:
First Name:MARITES
Middle Name:TALAVERA
Last Name:SERNA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 MORAINE WAY
Mailing Address - Street 2:
Mailing Address - City:HEATH
Mailing Address - State:TX
Mailing Address - Zip Code:75032-8904
Mailing Address - Country:US
Mailing Address - Phone:214-673-3511
Mailing Address - Fax:
Practice Address - Street 1:2409 ALCO AVE STE C
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-2614
Practice Address - Country:US
Practice Address - Phone:214-919-2399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36642183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist