Provider Demographics
NPI:1942570411
Name:SCANLON, PATRICK LEO (RPH)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:LEO
Last Name:SCANLON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11418 VIA SANTA BRISA
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-4260
Mailing Address - Country:US
Mailing Address - Phone:760-473-7105
Mailing Address - Fax:
Practice Address - Street 1:8251 MIRA MESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-2603
Practice Address - Country:US
Practice Address - Phone:858-357-2003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42057183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist