Provider Demographics
NPI:1245516681
Name:PENALOSA, MANUELITA PAVON (RPH)
Entity type:Individual
Prefix:MRS
First Name:MANUELITA
Middle Name:PAVON
Last Name:PENALOSA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4306 THUNDER TWICE STREET
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129
Mailing Address - Country:US
Mailing Address - Phone:702-340-4726
Mailing Address - Fax:
Practice Address - Street 1:6401 WEST CHARLESTON BOULEVARD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146
Practice Address - Country:US
Practice Address - Phone:702-259-7002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16396183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist