Healthcare Provider Details

I. General information

NPI: 1679217798
Provider Name (Legal Business Name): CAROL YACOUB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 04/25/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 HEALTH SCIENCES DR
LA JOLLA CA
92093-1503
US

IV. Provider business mailing address

9045 JUDICIAL DR APT 1429
SAN DIEGO CA
92122-4651
US

V. Phone/Fax

Practice location:
  • Phone: 858-822-6094
  • Fax:
Mailing address:
  • Phone: 631-275-7887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number72865
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: