Healthcare Provider Details

I. General information

NPI: 1386827756
Provider Name (Legal Business Name): SHERWIN GAJETON ESTABILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2007
Last Update Date: 12/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3719 VILLA TER APARTMENT # 4
SAN DIEGO CA
92104-3367
US

IV. Provider business mailing address

3719 VILLA TER APARTMENT # 4
SAN DIEGO CA
92104-3367
US

V. Phone/Fax

Practice location:
  • Phone: 757-286-2199
  • Fax:
Mailing address:
  • Phone: 757-286-2199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number69548
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: