Healthcare Provider Details

I. General information

NPI: 1114346590
Provider Name (Legal Business Name): MALLORY CRUZ PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

290 N WAYTE LN
FRESNO CA
93701-2124
US

IV. Provider business mailing address

PO BOX 1232
FRESNO CA
93715-1232
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-5030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number65798
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: