Healthcare Provider Details

I. General information

NPI: 1578902102
Provider Name (Legal Business Name): LIJAN PUTHUVALIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14340 PENASQUITOS DR
SAN DIEGO CA
92129-1602
US

IV. Provider business mailing address

PO BOX 928233
SAN DIEGO CA
92192-8233
US

V. Phone/Fax

Practice location:
  • Phone: 858-672-2598
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number61994
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: