Healthcare Provider Details

I. General information

NPI: 1841853165
Provider Name (Legal Business Name): JASMIN TIBAYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4570 ATLANTIC AVE
LONG BEACH CA
90807-1513
US

IV. Provider business mailing address

4570 ATLANTIC AVE
LONG BEACH CA
90807-1513
US

V. Phone/Fax

Practice location:
  • Phone: 562-644-2065
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number53370
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: