Healthcare Provider Details

I. General information

NPI: 1790109940
Provider Name (Legal Business Name): MARIA FIDELIS BACOLOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 HAWTHORNE BLVD
REDONDO BEACH CA
90278-3923
US

IV. Provider business mailing address

1413 HAWTHORNE BLVD
REDONDO BEACH CA
90278-3923
US

V. Phone/Fax

Practice location:
  • Phone: 310-370-8784
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number55737
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number55737
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: