=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720328453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TILTON NGUYEN PHARMACEUTICAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2013
-----------------------------------------------------
Last Update Date | 04/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15433 W SAND ST STE 102
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92392-2903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-241-4080
-----------------------------------------------------
Fax | 760-241-4171
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15433 W SAND ST STE 102
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92392-2903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-241-4080
-----------------------------------------------------
Fax | 760-241-4171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | PAULINE TILTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-241-4080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 53859
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------