Provider Demographics
NPI:1356946982
Name:TAYU, FAI WILFRED (RPH)
Entity type:Individual
Prefix:
First Name:FAI
Middle Name:WILFRED
Last Name:TAYU
Suffix:
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 1:4600 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-6214
Mailing Address - Country:US
Mailing Address - Phone:210-824-1679
Mailing Address - Fax:
Practice Address - Street 1:4600 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-6214
Practice Address - Country:US
Practice Address - Phone:210-824-1679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist