Healthcare Provider Details

I. General information

NPI: 1013079334
Provider Name (Legal Business Name): AIR FORCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2569 SHOREY WAY
FAIRFIELD CA
94533-6562
US

IV. Provider business mailing address

2569 SHOREY WAY
FAIRFIELD CA
94533-6562
US

V. Phone/Fax

Practice location:
  • Phone: 707-816-8622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number4679
License Number StatePR

VIII. Authorized Official

Name: MARCOS J LOPEZ
Title or Position: CLINICAL PHARMACIST
Credential:
Phone: 707-423-3459