MEDICARE: JUANITA VENECIA MAGARDIE PHARMACIST

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	183500000X	Pharmacist	63866	CA

General Provider Information

NPI Number	:	1134433683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUANITA VENECIA MAGARDIE PHARMACIST

Provider Business Mailing Address
First Line	:	645 LAKE ST
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95531-2011
Country	:	US
Telephone Number	:	707-291-7631
Fax Number	:

Provider Business Practice Location Address
First Line	:	645 LAKE ST
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95531-2011
Country	:	US
Telephone Number	:	707-291-7631
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2010
Last Update Date	:	07/27/2010

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