Provider Demographics
NPI:1912291204
Name:OLIVARES, ROBERTO ROLANDO (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:ROLANDO
Last Name:OLIVARES
Suffix:
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 1:5625 EIGER RD
Mailing Address - Street 2:150
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735
Mailing Address - Country:US
Mailing Address - Phone:956-693-4222
Mailing Address - Fax:512-487-5311
Practice Address - Street 1:5625 EIGER RD STE 150
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8980
Practice Address - Country:US
Practice Address - Phone:512-693-4222
Practice Address - Fax:512-487-5311
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist