Healthcare Provider Details

I. General information

NPI: 1417968090
Provider Name (Legal Business Name): SHAWKI BACHOUA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

779 PALM AVE
IMPERIAL BEACH CA
91932-1234
US

IV. Provider business mailing address

779 PALM AVE
IMPERIAL BEACH CA
91932-1234
US

V. Phone/Fax

Practice location:
  • Phone: 619-424-5164
  • Fax: 619-423-8492
Mailing address:
  • Phone: 619-424-5164
  • Fax: 619-423-8492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY43632
License Number StateCA

VIII. Authorized Official

Name: SHAWKI BACHOUA
Title or Position: OWNER
Credential:
Phone: 619-424-5559