Healthcare Provider Details

I. General information

NPI: 1235450859
Provider Name (Legal Business Name): WINNIE ANNE FABROA MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8760 19TH STREET
RANCHO CUCAMONGA CA
91701-9173
US

IV. Provider business mailing address

8760 19TH STREET
RANCHO CUCAMONGA CA
91701-9173
US

V. Phone/Fax

Practice location:
  • Phone: 909-989-3235
  • Fax: 909-481-0327
Mailing address:
  • Phone: 909-989-3235
  • Fax: 909-481-0327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60845
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: