Provider Demographics
NPI:1194877449
Name:FIDEL G HUERTA JR INC
Entity type:Organization
Organization Name:FIDEL G HUERTA JR INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FIDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HUERTA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:210-433-9991
Mailing Address - Street 1:818 BROOKLYN AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1607
Mailing Address - Country:US
Mailing Address - Phone:210-228-0300
Mailing Address - Fax:210-228-0313
Practice Address - Street 1:818 BROOKLYN AVE STE 2
Practice Address - Street 2:STE 2
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1607
Practice Address - Country:US
Practice Address - Phone:210-228-0300
Practice Address - Fax:210-228-0313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX238023336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX320248Medicaid
4506006OtherNCPDP PROVIDER IDENTIFICATION NUMBER