MEDICARE: SAN DIEGO PHARMACY

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	333600000X	Pharmacy	PHY39527	CA
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5617280	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376585679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN DIEGO PHARMACY

Provider Business Mailing Address
First Line	:	4711 UNIVERSITY AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1903
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4711 UNIVERSITY AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1903
Country	:	US
Telephone Number	:	619-283-3233
Fax Number	:	619-283-9118

Authorized Official
Title or Position	:	OWNER
Name	:	GEORGE TO
Credential	:
Telephone Number	:	619-283-3233

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	09/11/2025

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Directions to “SAN DIEGO PHARMACY ” Practice Location

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