=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992164008
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON CORCORAN PHARMD, BCPS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2016
-----------------------------------------------------
Last Update Date | 02/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 S MAIN ST
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92882-3420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-736-6200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11755 MALAGA DR UNIT 1070
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-8124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-893-1098
-----------------------------------------------------
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 | 65452
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 28RI03359500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------