Healthcare Provider Details

I. General information

NPI: 1679573042
Provider Name (Legal Business Name): GERALD G MEDLEY I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 CAMINO DE LOS MARES
SAN CLEMENTE CA
92673-2840
US

IV. Provider business mailing address

222 CALLE MARINA
SAN CLEMENTE CA
92672-4315
US

V. Phone/Fax

Practice location:
  • Phone: 949-496-0123
  • Fax: 949-496-0489
Mailing address:
  • Phone: 949-361-4939
  • Fax: 949-496-0489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number31827
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: