MEDICARE: CSU DOMINGUEZ HILLS PHARMACY

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	261QS1000X	Student Health Clinic/Center		CA

General Provider Information

NPI Number	:	1457483083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CSU DOMINGUEZ HILLS PHARMACY

Provider Business Mailing Address
First Line	:	1000 E VICTORIA ST
Second Line	:
City	:	CARSON
State	:	CA
Zip	:	90747-0001
Country	:	US
Telephone Number	:	310-243-3194
Fax Number	:	310-243-6990

Provider Business Practice Location Address
First Line	:	1000 E VICTORIA ST
Second Line	:
City	:	CARSON
State	:	CA
Zip	:	90747-0001
Country	:	US
Telephone Number	:	310-243-3194
Fax Number	:	310-243-6990

Authorized Official
Title or Position	:	PHARMACIST
Name	:	CLYDE FUGAMI
Credential	:
Telephone Number	:	310-243-3194

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/10/2008

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