MEDICARE: MAGDALENA REAL

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	71711	CA

General Provider Information

NPI Number	:	1417435066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAGDALENA REAL

Provider Business Mailing Address
First Line	:	1360 EASTLAKE PKWY
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91915-4116
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1360 EASTLAKE PKWY
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91915-4116
Country	:	US
Telephone Number	:	619-421-9432
Fax Number	:

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

Provider Enumeration Date	:	08/04/2018
Last Update Date	:	08/04/2018

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Directions to “ MAGDALENA REAL ” Practice Location

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