Provider Demographics
NPI:1770828451
Name:CAMACHO, ALBERT
Entity Type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:
Last Name:CAMACHO
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 1:550 YUCCA AVE
Mailing Address - Street 2:APT J120
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-3223
Mailing Address - Country:US
Mailing Address - Phone:808-497-1776
Mailing Address - Fax:760-380-1922
Practice Address - Street 1:170 INNER LOOP CR
Practice Address - Street 2:ROOM 207- MARY WALKER CLINIC
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310-5109
Practice Address - Country:US
Practice Address - Phone:760-380-3130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH-1350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist