MEDICARE: MATTHEW JOHN FAGUNDES

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	73417	CA

General Provider Information

NPI Number	:	1700367562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW JOHN FAGUNDES

Provider Business Mailing Address
First Line	:	2730 SHAFFER RD
Second Line	:
City	:	ATWATER
State	:	CA
Zip	:	95301-2225
Country	:	US
Telephone Number	:	209-357-9430
Fax Number	:	209-357-9595

Provider Business Practice Location Address
First Line	:	2730 SHAFFER RD
Second Line	:
City	:	ATWATER
State	:	CA
Zip	:	95301-2225
Country	:	US
Telephone Number	:	209-357-9430
Fax Number	:	209-357-9595

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

Provider Enumeration Date	:	08/28/2018
Last Update Date	:	08/28/2018

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