=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891496642
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUBEN RAY QUIROZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2023
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2130 E HIGHLAND AVE
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92404-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-862-4678
-----------------------------------------------------
Fax | 909-862-0517
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 724
-----------------------------------------------------
City | PATTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92369-0724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-262-9952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number | TCH190687
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------