Provider Demographics
NPI:1861870123
Name:MEDICAL CENTER PHARMACY, LTD.CO
Entity type:Organization
Organization Name:MEDICAL CENTER PHARMACY, LTD.CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:VALDIVIESO
Authorized Official - Suffix:III
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:210-833-1935
Mailing Address - Street 1:540 OAK CENTRE DRIVE
Mailing Address - Street 2:SUITE 153
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3937
Mailing Address - Country:US
Mailing Address - Phone:210-332-9862
Mailing Address - Fax:210-332-9585
Practice Address - Street 1:540 OAK CENTRE DRIVE
Practice Address - Street 2:SUITE 153
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3937
Practice Address - Country:US
Practice Address - Phone:210-332-9862
Practice Address - Fax:210-332-9585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX297103336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151574OtherPK