1972692051 NPI number — ANDRES E DOMINGUEZ PHARM D

Table of content: ANDRES E DOMINGUEZ PHARM D (NPI 1972692051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972692051 NPI number — ANDRES E DOMINGUEZ PHARM D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMINGUEZ
Provider First Name:
ANDRES
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARM D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOMINGUEZ
Provider Other First Name:
ANDRES
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1972692051
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2055 N PERRIS BLVD
Provider Second Line Business Mailing Address:
SUITE A1
Provider Business Mailing Address City Name:
PERRIS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-943-8188
Provider Business Mailing Address Fax Number:
951-943-8199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2055 N PERRIS BLVD
Provider Second Line Business Practice Location Address:
SUITE A1
Provider Business Practice Location Address City Name:
PERRIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-943-8188
Provider Business Practice Location Address Fax Number:
951-943-8199
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH36435 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RPH36435 . This is a "CA STATE BOARD OF PHCY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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