Basic Information
| Provider Information | |||||||||
| NPI: | 1699003772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANSELMO | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | JEROME | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | RPH, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2102 SAN MIGUEL DR | ||||||||
| Address2: | |||||||||
| City: | FRIENDSWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775465915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819960350 | ||||||||
| FaxNumber: | 2819961750 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 N FRIENDSWOOD DR | ||||||||
| Address2: | |||||||||
| City: | FRIENDSWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775463747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819923413 | ||||||||
| FaxNumber: | 2819924080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2009 | ||||||||
| LastUpdateDate: | 12/01/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 024391 | TX | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.