Provider Demographics
NPI:1952997348
Name:MEDINA, TRINIDAD
Entity Type:Individual
Prefix:
First Name:TRINIDAD
Middle Name:
Last Name:MEDINA
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 1:618 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DONNA
Mailing Address - State:TX
Mailing Address - Zip Code:78537-2755
Mailing Address - Country:US
Mailing Address - Phone:956-464-2611
Mailing Address - Fax:
Practice Address - Street 1:618 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DONNA
Practice Address - State:TX
Practice Address - Zip Code:78537-2755
Practice Address - Country:US
Practice Address - Phone:956-464-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX324451835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty