Provider Demographics
NPI:1720452097
Name:HUERTA, FIDEL G JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:FIDEL
Middle Name:G
Last Name:HUERTA
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8530 FM 78
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-1032
Mailing Address - Country:US
Mailing Address - Phone:210-662-7764
Mailing Address - Fax:
Practice Address - Street 1:8530 FM 78
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109-1032
Practice Address - Country:US
Practice Address - Phone:210-662-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19708183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist