Healthcare Provider Details

I. General information

NPI: 1245598812
Provider Name (Legal Business Name): GLORIA C MEDINA PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 WHISTLING WIND CIRCLE
WALNUT CA
91789
US

IV. Provider business mailing address

603 WHISTLING WIND CIRCLE
WALNUT CA
91789
US

V. Phone/Fax

Practice location:
  • Phone: 626-622-4023
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number41564
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: