Provider Demographics
NPI:1821485699
Name:BONGALON, BEVERLY TAPIA
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:TAPIA
Last Name:BONGALON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:BONGALON-GIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD/MBA
Mailing Address - Street 1:2425 GEARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3358
Mailing Address - Country:US
Mailing Address - Phone:415-833-9701
Mailing Address - Fax:
Practice Address - Street 1:2425 GEARY BLVD
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3358
Practice Address - Country:US
Practice Address - Phone:415-833-9701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist