=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306451257
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMANUEL MAGNO OLIVARES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2020
-----------------------------------------------------
Last Update Date | 09/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30340 HAUN RD
-----------------------------------------------------
City | MENIFEE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92584-6806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-723-6152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4674 BANNISTER AVE
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91732-1708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 83007
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------