Provider Demographics
NPI:1649437070
Name:RENNER, MARY ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:RENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2243 MOUNTAIN MIST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258
Mailing Address - Country:US
Mailing Address - Phone:830-714-4750
Mailing Address - Fax:
Practice Address - Street 1:17440 HENDERSON PASS
Practice Address - Street 2:NORTH CENTRAL FEDERAL CLINIC- OUTPATIENT PHARMACY
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232
Practice Address - Country:US
Practice Address - Phone:210-483-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-11387183500000X
TX36489183500000X
IL051-291240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist