Healthcare Provider Details

I. General information

NPI: 1821122920
Provider Name (Legal Business Name): COMELIA MARIE GILMORE CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7129 MALEY ST
SAN DIEGO CA
92111-5708
US

IV. Provider business mailing address

7129 MALEY ST
SAN DIEGO CA
92111-5708
US

V. Phone/Fax

Practice location:
  • Phone: 858-712-3950
  • Fax:
Mailing address:
  • Phone: 858-712-3950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number320101050752239
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: