=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316535115
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN ROLANDO VARGAS-BOTEO PHARM.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2021
-----------------------------------------------------
Last Update Date | 01/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15940 QUANTICO RD STE 100
-----------------------------------------------------
City | APPLE VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92307-1300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-946-1414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14441 PALO ALTO CT
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92392-5435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-596-9181
-----------------------------------------------------
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 | 83136
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------