MEDICARE: MRS. MANUELITA PAVON PENALOSA 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	16396	NV

General Provider Information

NPI Number	:	1245516681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MANUELITA PAVON PENALOSA RPH

Provider Business Mailing Address
First Line	:	4306 THUNDER TWICE STREET
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129
Country	:	US
Telephone Number	:	702-340-4726
Fax Number	:

Provider Business Practice Location Address
First Line	:	6401 WEST CHARLESTON BOULEVARD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146
Country	:	US
Telephone Number	:	702-259-7002
Fax Number	:

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

Provider Enumeration Date	:	10/31/2011
Last Update Date	:	10/31/2011

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