Provider Demographics
NPI:1982313607
Name:BLANCO, MICHAEL ANGEL (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANGEL
Last Name:BLANCO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 S DEL SOL LN
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1816
Mailing Address - Country:US
Mailing Address - Phone:909-963-8994
Mailing Address - Fax:
Practice Address - Street 1:775 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1223
Practice Address - Country:US
Practice Address - Phone:909-621-6708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87169183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist