Healthcare Provider Details

I. General information

NPI: 1730568700
Provider Name (Legal Business Name): MARIE KATHLEEN FULGENCIO ESPIRITU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2015
Last Update Date: 05/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W MAIN ST
EL CENTRO CA
92243-2211
US

IV. Provider business mailing address

649 CACTUS ST
IMPERIAL CA
92251-2515
US

V. Phone/Fax

Practice location:
  • Phone: 760-352-5731
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberINT 34375
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: