Healthcare Provider Details

I. General information

NPI: 1912561630
Provider Name (Legal Business Name): NEAL YACOO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9085 JUDICIAL DRIVE #2137
SAN DIEGO CA
92122
US

IV. Provider business mailing address

PO BOX 461
JAMUL CA
91935-0461
US

V. Phone/Fax

Practice location:
  • Phone: 619-244-2880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number69761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: