Provider Demographics
NPI:1649304320
Name:BUENA VISTA PHARMACY, INC.
Entity type:Organization
Organization Name:BUENA VISTA PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:D
Authorized Official - Last Name:IBANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:210-674-1900
Mailing Address - Street 1:7323 MARBACH RD STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-1905
Mailing Address - Country:US
Mailing Address - Phone:210-674-1900
Mailing Address - Fax:210-674-5404
Practice Address - Street 1:7323 MARBACH RD STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-1905
Practice Address - Country:US
Practice Address - Phone:210-674-1900
Practice Address - Fax:210-674-5404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18224183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010729401Medicaid
TX067296601Medicaid
TX4567270OtherNABP
TX016578901Medicaid
TN142614Medicaid
TX016578901Medicaid