Healthcare Provider Details

I. General information

NPI: 1184796690
Provider Name (Legal Business Name): GOVERNMENT OF GUAM DEPARTMENT OF ADMINISTRATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 AS ABMAN DR
INARAJAN GU
96917
US

IV. Provider business mailing address

123 CHALAN KARETA
MANGILAO GU
96913-6304
US

V. Phone/Fax

Practice location:
  • Phone: 671-828-7547
  • Fax: 671-828-7504
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPCY011
License Number StateGU

VIII. Authorized Official

Name: MICHELLE DELOSO
Title or Position: PHARMACY MANAGER
Credential: RPH
Phone: 671-635-7447