MEDICARE: MAYRA ESTRADA

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	183700000X	Pharmacy Technician	35703	CA

General Provider Information

NPI Number	:	1396413217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYRA ESTRADA

Provider Business Mailing Address
First Line	:	15425 WASHOAN RD
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92307-3261
Country	:	US
Telephone Number	:	323-812-2554
Fax Number	:

Provider Business Practice Location Address
First Line	:	13720 BEAR VALLEY RD
Second Line	:
City	:	VICTORVILLE
State	:	CA
Zip	:	92392-8713
Country	:	US
Telephone Number	:	760-955-2070
Fax Number	:

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

Provider Enumeration Date	:	09/03/2021
Last Update Date	:	09/03/2021

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