Basic Information
| Provider Information | |||||||||
| NPI: | 1306149141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF TEXAS EL PASO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UNIVERSITY OF TEXAS AT EL PASO STUDENT HEALTH CENTER PHARMAC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 W UNIVERSITY AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799680002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157476545 | ||||||||
| FaxNumber: | 9157475015 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 W UNIVERSITY AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799680002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157476545 | ||||||||
| FaxNumber: | 9157475015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2010 | ||||||||
| LastUpdateDate: | 07/15/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOONE | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST IN CHARGE | ||||||||
| AuthorizedOfficialTelephone: | 9157476545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | 6401 | TX | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2102819 | 01 | PK | OTHER |