Basic Information
| Provider Information | |||||||||
| NPI: | 1871686840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARDENAS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R.PH. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | QUEZADA | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R PH | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7400 MERTON MINTER ST | ||||||||
| Address2: | (119) | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106175300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7400 MERTON MINTER ST | ||||||||
| Address2: | (119) | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106175300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1200X | 27590 | TX | Y | Pharmacy Service Providers | Pharmacist | Pharmacotherapy |
ID Information
| ID | Type | State | Issuer | Description | 27590 | 01 | TX | TEXAS STATE BOARD LICENSE | OTHER |