Provider Demographics
NPI:1205106630
Name:TAYABEN, REGINALD PEREZ (PHARMD)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:PEREZ
Last Name:TAYABEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 W ORANGE SHOW RD
Mailing Address - Street 2:T-0188
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2029
Mailing Address - Country:US
Mailing Address - Phone:909-379-0003
Mailing Address - Fax:909-379-0005
Practice Address - Street 1:499 W ORANGE SHOW RD
Practice Address - Street 2:T-0188
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2029
Practice Address - Country:US
Practice Address - Phone:909-379-0003
Practice Address - Fax:909-379-0005
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-02
Last Update Date:2012-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66760183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist