=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114373446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACE GARCIA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2016
-----------------------------------------------------
Last Update Date | 05/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15286 SUMMIT AVE
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92336-0231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-463-9255
-----------------------------------------------------
Fax | 909-646-7679
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15286 SUMMIT AVE
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92336-0231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-463-9255
-----------------------------------------------------
Fax | 909-646-7679
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 45470
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------