Healthcare Provider Details

I. General information

NPI: 1225400385
Provider Name (Legal Business Name): FADI MATLOOB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2015
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3345 SPORTS ARENA BLVD
SAN DIEGO CA
92110-4567
US

IV. Provider business mailing address

3345 SPORTS ARENA BLVD
SAN DIEGO CA
92110-4567
US

V. Phone/Fax

Practice location:
  • Phone: 619-222-5818
  • Fax:
Mailing address:
  • Phone: 619-222-5818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number72881
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: