MEDICARE: MACTOR, INC.

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	3336L0003X	Long Term Care Pharmacy

General Provider Information

NPI Number	:	1801489323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MACTOR, INC.

Provider Business Mailing Address
First Line	:	4428 GLACIER AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3304
Country	:	US
Telephone Number	:	916-993-0212
Fax Number	:

Provider Business Practice Location Address
First Line	:	4428 GLACIER AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3304
Country	:	US
Telephone Number	:	916-993-0212
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MITESH PATEL
Credential	:	PHARMD
Telephone Number	:	619-269-6600

Provider Enumeration Date	:	02/16/2021
Last Update Date	:	02/16/2021

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Directions to “MACTOR, INC. ” Practice Location

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