Provider Demographics
NPI:1053639526
Name:CANALES, JORGE LUIS (RPH)
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LUIS
Last Name:CANALES
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 1:1911 NE BOB BULLOCK LOOP
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-6596
Mailing Address - Country:US
Mailing Address - Phone:956-764-5055
Mailing Address - Fax:956-764-5081
Practice Address - Street 1:1911 NE BOB BULLOCK LOOP
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045-6596
Practice Address - Country:US
Practice Address - Phone:956-764-5055
Practice Address - Fax:956-764-5081
Is Sole Proprietor?:No
Enumeration Date:2010-05-09
Last Update Date:2010-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31843183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist