Provider Demographics
NPI:1710275300
Name:FAJILAN, MYRA MAGTIBAY
Entity Type:Individual
Prefix:MISS
First Name:MYRA
Middle Name:MAGTIBAY
Last Name:FAJILAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9737 SAGE THRASHER CIR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-8125
Mailing Address - Country:US
Mailing Address - Phone:530-550-1080
Mailing Address - Fax:
Practice Address - Street 1:8368 ELK GROVE FLORIN RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95829-9228
Practice Address - Country:US
Practice Address - Phone:916-681-3558
Practice Address - Fax:916-681-2893
Is Sole Proprietor?:No
Enumeration Date:2011-07-15
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65125183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist