Healthcare Provider Details

I. General information

NPI: 1568429736
Provider Name (Legal Business Name): ALFRED MICHAEL FAGUNDES RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 M ST
CRESCENT CITY CA
95531-4129
US

IV. Provider business mailing address

125 PINE VIEW CT P.O. BOX 2123
CRESCENT CITY CA
95531-9167
US

V. Phone/Fax

Practice location:
  • Phone: 707-465-3663
  • Fax: 707-464-8533
Mailing address:
  • Phone: 707-464-8449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24038
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9086
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2111
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: