Provider Demographics
NPI:1699531947
Name:ANGELES, JUSTIN GABRIEL MEJIA
Entity type:Individual
Prefix:
First Name:JUSTIN GABRIEL
Middle Name:MEJIA
Last Name:ANGELES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2057 BOREALIS CIR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-4478
Mailing Address - Country:US
Mailing Address - Phone:916-827-8581
Mailing Address - Fax:
Practice Address - Street 1:2222 GRASS VALLEY HWY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2536
Practice Address - Country:US
Practice Address - Phone:530-889-8003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist