=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578342192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FARMACIA DE ANZA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2023
-----------------------------------------------------
Last Update Date | 09/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 E BIRCH ST STE D
-----------------------------------------------------
City | CALEXICO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92231-4526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-890-5977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 E BIRCH ST STE D
-----------------------------------------------------
City | CALEXICO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92231-4526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-890-5977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO/PRESIDENT
-----------------------------------------------------
Name | MR. GARY DAVID METELSKI
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 760-234-9171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------