MEDICARE: DOMINIQUE DEBOLD PHARMD

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	76191	CA

General Provider Information

NPI Number	:	1316473135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE DEBOLD PHARMD

Provider Business Mailing Address
First Line	:	680 COLLEEN DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95123-5512
Country	:	US
Telephone Number	:	415-894-0128
Fax Number	:

Provider Business Practice Location Address
First Line	:	6247 GRAHAM HILL RD
Second Line	:
City	:	FELTON
State	:	CA
Zip	:	95018-9723
Country	:	US
Telephone Number	:	831-335-6403
Fax Number	:

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

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	05/11/2017

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