=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730568700
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIE KATHLEEN FULGENCIO ESPIRITU
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2015
-----------------------------------------------------
Last Update Date | 05/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 W MAIN ST
-----------------------------------------------------
City | EL CENTRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92243-2211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-352-5731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 649 CACTUS ST
-----------------------------------------------------
City | IMPERIAL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92251-2515
-----------------------------------------------------
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 | INT 34375
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------