Provider Demographics
NPI:1053923367
Name:FRAUSTO, RILEY CHARLES
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:CHARLES
Last Name:FRAUSTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8711 BOWENS CROSSING ST APT 7102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78250-2773
Mailing Address - Country:US
Mailing Address - Phone:254-462-1044
Mailing Address - Fax:
Practice Address - Street 1:502 NEW VALLEY HI DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-4394
Practice Address - Country:US
Practice Address - Phone:210-673-0817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63567183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist