MEDICARE: MRS. THERESA KORBONSKI PRUITT RPH

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	27567	CA

General Provider Information

NPI Number	:	1558680538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. THERESA KORBONSKI PRUITT RPH

Provider Business Mailing Address
First Line	:	801 N EL CAMINO REAL
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4649
Country	:	US
Telephone Number	:	949-498-6752
Fax Number	:	949-498-1779

Provider Business Practice Location Address
First Line	:	801 N EL CAMINO REAL
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4649
Country	:	US
Telephone Number	:	949-498-6752
Fax Number	:	949-498-1779

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

Provider Enumeration Date	:	05/31/2010
Last Update Date	:	05/31/2010

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Directions to “ MRS. THERESA KORBONSKI PRUITT RPH” Practice Location

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