Healthcare Provider Details

I. General information

NPI: 1619666443
Provider Name (Legal Business Name): CHRISTIAN OSCAR CEVALLOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ROUTE 73
VOORHEES NJ
08043-9573
US

IV. Provider business mailing address

130 FENWAY AVE
ATCO NJ
08004-3017
US

V. Phone/Fax

Practice location:
  • Phone: 856-768-1801
  • Fax:
Mailing address:
  • Phone: 856-264-9568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04305200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: