Provider Demographics
NPI:1073938791
Name:ABOUCHABKI, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ABOUCHABKI
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 1:12998 DEER CANYON CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-4218
Mailing Address - Country:US
Mailing Address - Phone:858-220-5081
Mailing Address - Fax:619-222-5879
Practice Address - Street 1:3345 SPORTS ARENA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4567
Practice Address - Country:US
Practice Address - Phone:619-222-5818
Practice Address - Fax:619-222-5879
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist