Provider Demographics
NPI:1700475431
Name:SAN AGUSTIN, SHAYNE RICHARD QUITO (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHAYNE
Middle Name:RICHARD QUITO
Last Name:SAN AGUSTIN
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 1:3269 SAN MARCO WAY
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-2711
Mailing Address - Country:US
Mailing Address - Phone:510-378-5898
Mailing Address - Fax:
Practice Address - Street 1:3269 SAN MARCO WAY
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-2711
Practice Address - Country:US
Practice Address - Phone:510-378-5898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-17
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83489183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist