=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568730786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUBEN MALDONADO PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2011
-----------------------------------------------------
Last Update Date | 12/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14102 RAMONA BLVD
-----------------------------------------------------
City | BALDWIN PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91706-3138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-337-1082
-----------------------------------------------------
Fax | 626-960-9073
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 703 E HANKS ST
-----------------------------------------------------
City | AZUSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91702-3809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-337-1082
-----------------------------------------------------
Fax | 626-960-9073
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 59784
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------