Provider Demographics
NPI:1699003772
Name:ANSELMO, VINCENT JEROME JR (RPH,)
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:JEROME
Last Name:ANSELMO
Suffix:JR
Gender:M
Credentials:RPH,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 SAN MIGUEL DR
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-5915
Mailing Address - Country:US
Mailing Address - Phone:281-996-0350
Mailing Address - Fax:281-996-1750
Practice Address - Street 1:102 N FRIENDSWOOD DR
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-3747
Practice Address - Country:US
Practice Address - Phone:281-992-3413
Practice Address - Fax:281-992-4080
Is Sole Proprietor?:No
Enumeration Date:2009-11-30
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX024391183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist