Provider Demographics
NPI:1386248748
Name:LOPEZ, MICHELLE RODRIGUEZ
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RODRIGUEZ
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 SHADBUSH ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-2797
Mailing Address - Country:US
Mailing Address - Phone:210-269-8314
Mailing Address - Fax:
Practice Address - Street 1:9006 GUILBEAU RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78250-2652
Practice Address - Country:US
Practice Address - Phone:210-536-3158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55491183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist