Provider Demographics
NPI:1366046542
Name:ACEVEDO, LUIS ARIEL
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ARIEL
Last Name:ACEVEDO
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 1:1812 PASEO REAL CIR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-3705
Mailing Address - Country:US
Mailing Address - Phone:915-204-4022
Mailing Address - Fax:
Practice Address - Street 1:300 S ZARAGOZA RD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79907-6635
Practice Address - Country:US
Practice Address - Phone:915-790-5722
Practice Address - Fax:915-790-5721
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist