Provider Demographics
NPI:1801330303
Name:PRESIDIO PHARMACY INC
Entity type:Organization
Organization Name:PRESIDIO PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:X
Authorized Official - Last Name:JUAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:432-336-2297
Mailing Address - Street 1:PO BOX 2044
Mailing Address - Street 2:
Mailing Address - City:PRESIDIO
Mailing Address - State:TX
Mailing Address - Zip Code:79845-2044
Mailing Address - Country:US
Mailing Address - Phone:432-229-2252
Mailing Address - Fax:
Practice Address - Street 1:1501 B NORTH ERMA AVE
Practice Address - Street 2:
Practice Address - City:PRESIDIO
Practice Address - State:TX
Practice Address - Zip Code:79845
Practice Address - Country:US
Practice Address - Phone:432-229-2252
Practice Address - Fax:432-229-3152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX31099OtherPHARMACY LICENSE NUMBER