Healthcare Provider Details

I. General information

NPI: 1679787675
Provider Name (Legal Business Name): MARJORIE TUDLONG MCDONOUGH PHARMACY TECHNICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

IV. Provider business mailing address

16914 TORBETT LN #13
SAN DIEGO CA
92127-6803
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-8033
  • Fax:
Mailing address:
  • Phone: 619-692-8033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number4306
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: