Provider Demographics
NPI:1649871153
Name:GUAJARDO, JAY
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:GUAJARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 N GLASSCOCK RD
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78573-8456
Mailing Address - Country:US
Mailing Address - Phone:956-655-9079
Mailing Address - Fax:
Practice Address - Street 1:5700 N 23RD ST
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-3907
Practice Address - Country:US
Practice Address - Phone:956-800-6853
Practice Address - Fax:956-800-6854
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38004183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist