Healthcare Provider Details

I. General information

NPI: 1245833037
Provider Name (Legal Business Name): BJR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HARMON LOOP RD STE 100
DEDEDO GU
96929-6536
US

IV. Provider business mailing address

600 HARMON LOOP RD STE 100
DEDEDO GU
96929-6536
US

V. Phone/Fax

Practice location:
  • Phone: 671-649-6831
  • Fax:
Mailing address:
  • Phone: 671-649-6831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARY JEAN R CABILDO
Title or Position: MANAGER
Credential: PHARMACIST
Phone: 671-971-1655