Provider Demographics
NPI:1508523416
Name:ANGQUICO, MATTHEW TIMOTHY
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TIMOTHY
Last Name:ANGQUICO
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 1:13217 AURORA DR SPC 46
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-1813
Mailing Address - Country:US
Mailing Address - Phone:619-633-5900
Mailing Address - Fax:
Practice Address - Street 1:9532 WINTER GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-4032
Practice Address - Country:US
Practice Address - Phone:619-390-7342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-26
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA178781183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician