MEDICARE: MR. CARLO ENRICO CRISOLOGO 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	57891	CA

General Provider Information

NPI Number	:	1992114045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARLO ENRICO CRISOLOGO RPH

Provider Business Mailing Address
First Line	:	1250 E GIBSON RD
Second Line	:
City	:	WOODLAND
State	:	CA
Zip	:	95776-6315
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 E GIBSON RD
Second Line	:
City	:	WOODLAND
State	:	CA
Zip	:	95776-6315
Country	:	US
Telephone Number	:	530-665-4309
Fax Number	:	530-665-4310

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

Provider Enumeration Date	:	08/02/2014
Last Update Date	:	08/02/2014

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