Healthcare Provider Details

I. General information

NPI: 1962770990
Provider Name (Legal Business Name): ALMA IRENE BLACKMAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9119 JAMACHA RD 149
SPRING VALLEY CA
91977-4162
US

IV. Provider business mailing address

9119 JAMACHA RD 149
SPRING VALLEY CA
91977-4162
US

V. Phone/Fax

Practice location:
  • Phone: 619-248-0436
  • Fax: 619-713-0058
Mailing address:
  • Phone: 619-248-0436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number67560
License Number StateCA

VIII. Authorized Official

Name: ALMA IRENE BLACKMAN
Title or Position: PHARMACY TECHNICIAN
Credential:
Phone: 619-248-0436