Provider Demographics
NPI:1437555950
Name:SIMBULAN, JAMES DARREN DIZON
Entity Type:Individual
Prefix:
First Name:JAMES DARREN
Middle Name:DIZON
Last Name:SIMBULAN
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 1:2633 S AVERILL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-5630
Mailing Address - Country:US
Mailing Address - Phone:951-801-8062
Mailing Address - Fax:
Practice Address - Street 1:2633 S AVERILL AVE
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-5630
Practice Address - Country:US
Practice Address - Phone:951-801-8062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist