Provider Demographics
NPI:1386021780
Name:SAN DIEGO OPTIMUM COMPOUNDING
Entity Type:Organization
Organization Name:SAN DIEGO OPTIMUM COMPOUNDING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MAII
Authorized Official - Middle Name:
Authorized Official - Last Name:EL-SHATANOUFY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:858-699-6563
Mailing Address - Street 1:12265 SCRIPPS POWAY PKWY
Mailing Address - Street 2:SUITE 114
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-6151
Mailing Address - Country:US
Mailing Address - Phone:858-699-6563
Mailing Address - Fax:
Practice Address - Street 1:12265 SCRIPPS POWAY PKWY
Practice Address - Street 2:SUITE 114
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-6151
Practice Address - Country:US
Practice Address - Phone:858-699-6563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53633333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy