Provider Demographics
NPI:1083009914
Name:DOMINGO, EDWARD BALBINO COSME GARCIA (R PH)
Entity Type:Individual
Prefix:MR
First Name:EDWARD BALBINO
Middle Name:COSME GARCIA
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:583 N VENTU PARK RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-2710
Mailing Address - Country:US
Mailing Address - Phone:805-376-1380
Mailing Address - Fax:805-376-1862
Practice Address - Street 1:2320 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-7816
Practice Address - Country:US
Practice Address - Phone:805-928-7623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59921183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist