Provider Demographics
NPI:1598211930
Name:PAGE, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PAGE
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 1:82270 HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201
Mailing Address - Country:US
Mailing Address - Phone:760-342-2008
Mailing Address - Fax:760-775-4694
Practice Address - Street 1:82270 US HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5651
Practice Address - Country:US
Practice Address - Phone:760-342-2008
Practice Address - Fax:760-775-4694
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPX 28384183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist