Provider Demographics
NPI:1376198317
Name:DALMACIO, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:DALMACIO
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:PO BOX 9644
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96931-5644
Mailing Address - Country:US
Mailing Address - Phone:671-633-3684
Mailing Address - Fax:671-633-3680
Practice Address - Street 1:655 HARMON LOOP RD STE 108
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-6544
Practice Address - Country:US
Practice Address - Phone:671-633-3684
Practice Address - Fax:671-633-3680
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPH-075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUPH075OtherLICENSE NUMBER