Provider Demographics
NPI:1023662921
Name:TUCKER, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:TUCKER
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 1:2400 BIRKDALE LN
Mailing Address - Street 2:ADDRESS LINE 2
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 S RACHAL ST
Practice Address - Street 2:
Practice Address - City:SINTON
Practice Address - State:TX
Practice Address - Zip Code:78387-2524
Practice Address - Country:US
Practice Address - Phone:361-364-1416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28148183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist