MEDICARE: GERALD G MEDLEY I

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	31827	CA

General Provider Information

NPI Number	:	1679573042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALD G MEDLEY I

Provider Business Mailing Address
First Line	:	222 CALLE MARINA
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4315
Country	:	US
Telephone Number	:	949-361-4939
Fax Number	:	949-496-0489

Provider Business Practice Location Address
First Line	:	665 CAMINO DE LOS MARES
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92673-2840
Country	:	US
Telephone Number	:	949-496-0123
Fax Number	:	949-496-0489

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	07/08/2007

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Directions to “ GERALD G MEDLEY I ” Practice Location

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