Healthcare Provider Details

I. General information

NPI: 1154798908
Provider Name (Legal Business Name): HEIDI Z CEVALLOS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1988 HACIENDA DR
VISTA CA
92081-6026
US

IV. Provider business mailing address

425 W BEECH ST UNIT 434
SAN DIEGO CA
92101-2970
US

V. Phone/Fax

Practice location:
  • Phone: 760-295-2625
  • Fax: 760-295-2655
Mailing address:
  • Phone: 317-281-5662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number70252
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: