MEDICARE: MAE ANNE SEGOVIA BANANA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	88852	CA

General Provider Information

NPI Number	:	1184499709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAE ANNE SEGOVIA BANANA

Provider Business Mailing Address
First Line	:	553 REFOSCO CT
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94534-4129
Country	:	US
Telephone Number	:	530-567-9079
Fax Number	:

Provider Business Practice Location Address
First Line	:	2590 N TEXAS ST
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-1606
Country	:	US
Telephone Number	:	707-399-9329
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/24/2023
Last Update Date	:	11/24/2023

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Directions to “ MAE ANNE SEGOVIA BANANA ” Practice Location

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