MEDICARE: MACTOR, INC.

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	3336C0003X	Community/Retail Pharmacy	56091	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0534342	OTHER		NCPDP

General Provider Information

NPI Number	:	1740214790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MACTOR, INC.

Provider Business Mailing Address
First Line	:	11676 TREADWELL DR
Second Line	:
City	:	POWAY
State	:	CA
Zip	:	92064
Country	:	US
Telephone Number	:	619-466-3246
Fax Number	:	619-466-4134

Provider Business Practice Location Address
First Line	:	4428 GLACIER AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3304
Country	:	US
Telephone Number	:	619-466-3246
Fax Number	:	619-466-4134

Authorized Official
Title or Position	:	CEO
Name	:	MITESH PATEL
Credential	:	PHARM D
Telephone Number	:	619-466-3246

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	03/04/2020

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Directions to “MACTOR, INC. ” Practice Location

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