Provider Demographics
NPI:1053759613
Name:BOOTMAN, DIEGO (PHARMD)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:BOOTMAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2427 E EXPRESSWAY 83
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-8354
Mailing Address - Country:US
Mailing Address - Phone:956-928-7281
Mailing Address - Fax:
Practice Address - Street 1:2427 E EXPRESSWAY 83
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-8354
Practice Address - Country:US
Practice Address - Phone:956-928-7281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41259183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX41259OtherTEXAS PHARMACY LICENSE