Provider Demographics
NPI:1891888111
Name:JIMENEZ, MARIO ALFREDO (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:ALFREDO
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:MR
Other - First Name:MARIO
Other - Middle Name:ALFREDO
Other - Last Name:JIMENEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:14300 RAMONA BLVD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3241
Mailing Address - Country:US
Mailing Address - Phone:626-337-1550
Mailing Address - Fax:626-337-0660
Practice Address - Street 1:14300 RAMONA BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3241
Practice Address - Country:US
Practice Address - Phone:626-337-1550
Practice Address - Fax:626-337-0660
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH31058183500000X
CA0975410001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA358020Medicaid
CA0975410001Medicare NSC