Provider Demographics
NPI:1124060579
Name:SAN RAPHEL PHARMACY
Entity type:Organization
Organization Name:SAN RAPHEL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRANZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-463-3001
Mailing Address - Street 1:365 N MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:MERCEDES
Mailing Address - State:TX
Mailing Address - Zip Code:78570-2657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1337 EAST PALMA VISTA DRIVE SUITE B
Practice Address - Street 2:
Practice Address - City:PALM VIEW
Practice Address - State:TX
Practice Address - Zip Code:78539
Practice Address - Country:US
Practice Address - Phone:956-514-0955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24396333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4540022OtherOTHER ID NUMBER-COMMERCIAL NUMBER