Provider Demographics
NPI:1942794110
Name:CUBACHA, VIRGIL BALDIVINO
Entity Type:Individual
Prefix:
First Name:VIRGIL
Middle Name:BALDIVINO
Last Name:CUBACHA
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 1:1865 HERNDON AVE # K55
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6163
Mailing Address - Country:US
Mailing Address - Phone:562-760-3578
Mailing Address - Fax:
Practice Address - Street 1:3680 W SHAW AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3231
Practice Address - Country:US
Practice Address - Phone:559-277-8191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist