MEDICARE: A FAMILY PHARMACY-HESPERIA

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	PHY46638	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5614020	OTHER		OTHER ID NUMBER
2	5614020	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1356430045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A FAMILY PHARMACY-HESPERIA

Provider Business Mailing Address
First Line	:	PO BOX 900
Second Line	:
City	:	VICTORVILLE
State	:	CA
Zip	:	92393-0900
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11919 HESPERIA RD
Second Line	:	STE C
City	:	HESPERIA
State	:	CA
Zip	:	92345-1855
Country	:	US
Telephone Number	:	760-244-3777
Fax Number	:	760-242-8617

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS TEKELE
Credential	:	PHARMACIST
Telephone Number	:	760-242-5452

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	04/15/2008

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