Provider Demographics
NPI:1992444582
Name:REYES, CLARISSA
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:REYES
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 1:1620 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-4260
Mailing Address - Country:US
Mailing Address - Phone:903-533-0367
Mailing Address - Fax:
Practice Address - Street 1:4350 OLD OMEN RD APT 7203
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-2545
Practice Address - Country:US
Practice Address - Phone:361-442-8878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70395183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist