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Organization
SUPER DRUG MART INC
Active
Organization
SUPER DRUG MART INC
Active
Other names
SUPER DRUG MART
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RAYMOND D. IBANEZ SR. (OWNER/PHARMACIST)
(210) 884-2543
Entity
Organization
Contact information
Practice address
19010 PRIEST BLVD, LYTLE, TX 78052
(830) 709-0360
(830) 709-0363
Mailing address
19010 PRIEST BLVD, SUITE 101, LYTLE, TX 78052
(830) 709-0360
(830) 709-0363
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
20307
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
144974
—
TX
01
—
20307
STATE BOARD OF PHARMACY
TX
Enumeration date
01/12/2007
Last updated
05/19/2015
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