Provider Demographics
NPI:1083989420
Name:MEDLEY, EUGENE (PHARMD, MS)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:MEDLEY
Suffix:
Gender:M
Credentials:PHARMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 CAMINO DE LOS MARES STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2840
Mailing Address - Country:US
Mailing Address - Phone:949-496-0123
Mailing Address - Fax:949-496-0489
Practice Address - Street 1:665 CAMINO DE LOS MARES STE 101
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2840
Practice Address - Country:US
Practice Address - Phone:949-496-0123
Practice Address - Fax:949-496-0489
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60551183500000X
CO17928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist