MEDICARE: UNIVERSITY OF CALIFORNIA, SAN DIEGO

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	PHY44965	CA

General Provider Information

NPI Number	:	1730321217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY OF CALIFORNIA, SAN DIEGO

Provider Business Mailing Address
First Line	:	200 W ARBOR DR
Second Line	:	MAIL CODE: 8208
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-9001
Country	:	US
Telephone Number	:	619-543-2688
Fax Number	:	619-543-3991

Provider Business Practice Location Address
First Line	:	220 DICKINSON ST
Second Line	:	SUITE: A
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-2071
Country	:	US
Telephone Number	:	619-543-2688
Fax Number	:	619-543-3991

Authorized Official
Title or Position	:	CLINIC SUPERVISOR
Name	:	MISS JILL ANN KUNKEL
Credential	:	RN
Telephone Number	:	619-543-8080

Provider Enumeration Date	:	03/31/2009
Last Update Date	:	01/14/2010

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