Provider Demographics
NPI:1306447669
Name:PIEDRA, JORGE (PHARMD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:PIEDRA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 TREEHOUSE LN S
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76262-8949
Mailing Address - Country:US
Mailing Address - Phone:817-312-0528
Mailing Address - Fax:
Practice Address - Street 1:1542 TREEHOUSE LN S
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76262-8949
Practice Address - Country:US
Practice Address - Phone:817-312-0528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43612183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX43612OtherPHARMACIST LICENSE NUMBER