MEDICARE: DESIREE SAHAGUN OTE PHARMACIST

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	62219	CA

General Provider Information

NPI Number	:	1790187623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESIREE SAHAGUN OTE PHARMACIST

Provider Business Mailing Address
First Line	:	525 W ACACIA ST
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95203-2405
Country	:	US
Telephone Number	:	209-461-3104
Fax Number	:

Provider Business Practice Location Address
First Line	:	9641 MARYNISSEN WAY
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95757-4616
Country	:	US
Telephone Number	:	760-977-8253
Fax Number	:

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

Provider Enumeration Date	:	09/23/2014
Last Update Date	:	11/11/2014

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