MEDICARE: GIDEON MORDECHAI SHAKKED RPH

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	62575	CA

General Provider Information

NPI Number	:	1184953747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GIDEON MORDECHAI SHAKKED RPH

Provider Business Mailing Address
First Line	:	PO BOX 13356
Second Line	:
City	:	LA JOLLA
State	:	CA
Zip	:	92039-3356
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11080 W OCEAN AIR DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-4657
Country	:	US
Telephone Number	:	858-405-0353
Fax Number	:

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

Provider Enumeration Date	:	12/10/2009
Last Update Date	:	12/10/2009

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