Healthcare Provider Details

I. General information

NPI: 1609194992
Provider Name (Legal Business Name): VIVIAN E CORDOVES RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 05/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 BAYSIDE DR
NEWPORT BEACH CA
92660-7462
US

IV. Provider business mailing address

25312 MAWSON DR
LAGUNA HILLS CA
92653-5244
US

V. Phone/Fax

Practice location:
  • Phone: 949-760-0111
  • Fax:
Mailing address:
  • Phone: 949-837-4048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number31716
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: