Healthcare Provider Details

I. General information

NPI: 1700367562
Provider Name (Legal Business Name): MATTHEW JOHN FAGUNDES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 SHAFFER RD
ATWATER CA
95301-2225
US

IV. Provider business mailing address

2730 SHAFFER RD
ATWATER CA
95301-2225
US

V. Phone/Fax

Practice location:
  • Phone: 209-357-9430
  • Fax: 209-357-9595
Mailing address:
  • Phone: 209-357-9430
  • Fax: 209-357-9595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number73417
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: