=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265220974
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FABIOLA MARIE GALLARDO PENCHI PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2025
-----------------------------------------------------
Last Update Date | 04/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 918 W PLATT ST STE 2
-----------------------------------------------------
City | MAQUOKETA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52060-2063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-652-5611
-----------------------------------------------------
Fax | 563-652-6242
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 S MAIN ST UNIT 2A
-----------------------------------------------------
City | MAQUOKETA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52060-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-431-5655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 25266
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------