MEDICARE: YVONNE COSTELLO

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	10614	NV
2	183500000X	Pharmacist	43133	CA

General Provider Information

NPI Number	:	1972914604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YVONNE COSTELLO

Provider Business Mailing Address
First Line	:	930 TAHOE BLVD
Second Line	:
City	:	INCLINE VILLAGE
State	:	NV
Zip	:	89451-9451
Country	:	US
Telephone Number	:	775-831-3111
Fax Number	:	775-831-9116

Provider Business Practice Location Address
First Line	:	930 TAHOE BLVD
Second Line	:
City	:	INCLINE VILLAGE
State	:	NV
Zip	:	89451-9451
Country	:	US
Telephone Number	:	775-831-3111
Fax Number	:	775-831-9116

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

Provider Enumeration Date	:	05/15/2014
Last Update Date	:	05/15/2014

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Directions to “ YVONNE COSTELLO ” Practice Location

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