Healthcare Provider Details

I. General information

NPI: 1659795342
Provider Name (Legal Business Name): ROBERTO DATILES RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2014
Last Update Date: 04/04/2020
Certification Date: 04/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N 2ND ST
EL CAJON CA
92021-7243
US

IV. Provider business mailing address

7865 STARLING DR
SAN DIEGO CA
92123-2747
US

V. Phone/Fax

Practice location:
  • Phone: 619-401-0761
  • Fax:
Mailing address:
  • Phone: 619-665-9271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH60120621
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number66710
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number66710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: