Provider Demographics
NPI:1962744532
Name:BAZALDUA, MARIE DIANE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:DIANE
Last Name:BAZALDUA
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 1:310 FURR DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-4415
Mailing Address - Country:US
Mailing Address - Phone:210-290-7430
Mailing Address - Fax:
Practice Address - Street 1:2135 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-4895
Practice Address - Country:US
Practice Address - Phone:830-773-0420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist