Provider Demographics
NPI:1770529778
Name:ROMEO V VILLANUEVA
Entity type:Organization
Organization Name:ROMEO V VILLANUEVA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROMEO
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-280-1254
Mailing Address - Street 1:4456 VANDEVER AVE
Mailing Address - Street 2:STE 5
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3320
Mailing Address - Country:US
Mailing Address - Phone:619-280-1254
Mailing Address - Fax:619-280-1255
Practice Address - Street 1:4456 VANDEVER AVE
Practice Address - Street 2:STE 5
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3320
Practice Address - Country:US
Practice Address - Phone:619-280-1254
Practice Address - Fax:619-280-1255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 333600000X
CAPHY445293336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1992856OtherPK
CAPHA445290Medicaid
1318380001Medicare NSC