Healthcare Provider Details

I. General information

NPI: 1265872113
Provider Name (Legal Business Name): EGLIS ISMAR TELLEZ-CORRALES PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 29TH ST STE 690
SACRAMENTO CA
95816-5126
US

IV. Provider business mailing address

2350 HARBOR BLVD APT 103
COSTA MESA CA
92626-6258
US

V. Phone/Fax

Practice location:
  • Phone: 916-887-4670
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number62476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: