Healthcare Provider Details

I. General information

NPI: 1538748983
Provider Name (Legal Business Name): MCC SAN DIEGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 UNION ST
SAN DIEGO CA
92101-6030
US

IV. Provider business mailing address

808 UNION ST
SAN DIEGO CA
92101-6030
US

V. Phone/Fax

Practice location:
  • Phone: 619-232-4311
  • Fax:
Mailing address:
  • Phone: 619-232-4311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2400X
TaxonomyPrison Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ADAM LOYSON
Title or Position: CHIEF PHARMACIST, MCC SAN DIEGO
Credential:
Phone: 619-232-4311