Provider Demographics
NPI:1154921534
Name:NINO, MICHAEL MATTHEW
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MATTHEW
Last Name:NINO
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 1:1004 W OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS FRESNOS
Mailing Address - State:TX
Mailing Address - Zip Code:78566-3666
Mailing Address - Country:US
Mailing Address - Phone:956-233-1822
Mailing Address - Fax:956-233-1798
Practice Address - Street 1:1004 W OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:LOS FRESNOS
Practice Address - State:TX
Practice Address - Zip Code:78566-3666
Practice Address - Country:US
Practice Address - Phone:956-233-1822
Practice Address - Fax:956-233-1798
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist