Healthcare Provider Details

I. General information

NPI: 1043794894
Provider Name (Legal Business Name): OMAR J WOODWORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 HOWARD ST RM 130
SAN FRANCISCO CA
94103-2638
US

IV. Provider business mailing address

40 RAVILLA CT
DALY CITY CA
94014-1328
US

V. Phone/Fax

Practice location:
  • Phone: 415-255-3659
  • Fax:
Mailing address:
  • Phone: 510-827-6678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number134094
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: