Provider Demographics
NPI:1508927237
Name:DELVALLE, EFRAIN A (PHARMACIST)
Entity type:Individual
Prefix:
First Name:EFRAIN
Middle Name:A
Last Name:DELVALLE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 S PATRICK DRIVE
Mailing Address - Street 2:45TH MEDICAL GROUP
Mailing Address - City:PATRICK AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32925
Mailing Address - Country:US
Mailing Address - Phone:321-494-9313
Mailing Address - Fax:321-494-7997
Practice Address - Street 1:1381 S PATRICK DRIVE
Practice Address - Street 2:45TH MEDICAL GROUP
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925
Practice Address - Country:US
Practice Address - Phone:321-494-9313
Practice Address - Fax:321-494-7997
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR003803183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UAD000Medicare UPIN