Provider Demographics
NPI:1992840599
Name:CAVAZOS, MARY ALICE (CERTIFIED PHARMACY T)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ALICE
Last Name:CAVAZOS
Suffix:
Gender:F
Credentials:CERTIFIED PHARMACY T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243
Mailing Address - Country:US
Mailing Address - Phone:760-353-5130
Mailing Address - Fax:760-353-4556
Practice Address - Street 1:1600 S IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243
Practice Address - Country:US
Practice Address - Phone:760-353-5130
Practice Address - Fax:760-353-4556
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA350101060360213183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician