Provider Demographics
NPI:1831236413
Name:TITA & ERNESTO PADAYAO
Entity type:Organization
Organization Name:TITA & ERNESTO PADAYAO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TITA
Authorized Official - Middle Name:
Authorized Official - Last Name:PADAYAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-562-1006
Mailing Address - Street 1:3809 GAGE AVE
Mailing Address - Street 2:
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-1026
Mailing Address - Country:US
Mailing Address - Phone:323-562-1006
Mailing Address - Fax:323-562-4269
Practice Address - Street 1:3809 GAGE AVE
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-1026
Practice Address - Country:US
Practice Address - Phone:323-562-1006
Practice Address - Fax:323-562-4269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY300703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000904OtherPK
CAPHA300700Medicaid
CAPHA300700Medicaid