Provider Demographics
NPI:1730679978
Name:DE JESUS, EDMOND STO DOMINGO (PHARMD)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:STO DOMINGO
Last Name:DE JESUS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 S EMPIRE ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-2459
Mailing Address - Country:US
Mailing Address - Phone:714-512-7907
Mailing Address - Fax:
Practice Address - Street 1:216 WESTLAKE CTR
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-1430
Practice Address - Country:US
Practice Address - Phone:650-756-4535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist