Provider Demographics
NPI:1487250510
Name:BLACK, PATTI
Entity type:Individual
Prefix:
First Name:PATTI
Middle Name:
Last Name:BLACK
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 1:429 CONNOLLY CIR W
Mailing Address - Street 2:
Mailing Address - City:LOCKHART
Mailing Address - State:TX
Mailing Address - Zip Code:78644-2943
Mailing Address - Country:US
Mailing Address - Phone:512-376-8035
Mailing Address - Fax:
Practice Address - Street 1:1114 E SARAH DEWITT DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629
Practice Address - Country:US
Practice Address - Phone:830-672-2811
Practice Address - Fax:830-672-6544
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX024119183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist