Provider Demographics
NPI:1356125397
Name:PALOMO, JASON BUSTOS
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:BUSTOS
Last Name:PALOMO
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 1:29840 SAGUARO ST
Mailing Address - Street 2:
Mailing Address - City:CASTAIC
Mailing Address - State:CA
Mailing Address - Zip Code:91384-3574
Mailing Address - Country:US
Mailing Address - Phone:661-219-1004
Mailing Address - Fax:
Practice Address - Street 1:99 MONTECILLO RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3308
Practice Address - Country:US
Practice Address - Phone:415-444-2980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87905183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist