MEDICARE: MED MATRIX PHARMACY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2127529	OTHER		PK

General Provider Information

NPI Number	:	1093795577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MED MATRIX PHARMACY, INC

Provider Business Mailing Address
First Line	:	161 THUNDER DR STE 100
Second Line	:
City	:	VISTA
State	:	CA
Zip	:	92083-6051
Country	:	US
Telephone Number	:	760-758-7650
Fax Number	:	760-758-8228

Provider Business Practice Location Address
First Line	:	161 THUNDER DR
Second Line	:
City	:	VISTA
State	:	CA
Zip	:	92083-6016
Country	:	US
Telephone Number	:	760-758-7650
Fax Number	:	760-758-8228

Authorized Official
Title or Position	:	OWNER
Name	:	CONNIE K DAO
Credential	:
Telephone Number	:	760-758-7650

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	11/05/2024

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