Healthcare Provider Details

I. General information

NPI: 1144302928
Provider Name (Legal Business Name): DOMINGUEZ PHARMACY LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 N PERRIS BLVD STE A1
PERRIS CA
92571-2515
US

IV. Provider business mailing address

1175 E ARROW HWY SUITE K
UPLAND CA
91786-5525
US

V. Phone/Fax

Practice location:
  • Phone: 951-943-8188
  • Fax: 951-943-8199
Mailing address:
  • Phone: 909-981-1009
  • Fax: 909-981-3612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY43987
License Number StateCA

VIII. Authorized Official

Name: ANDRES DOMINGUEZ
Title or Position: GENERAL PARTNER / PIC
Credential: PHARM D
Phone: 951-943-8188