Provider Demographics
NPI:1366275315
Name:DOMINGO, PAOLO TRISTIAN
Entity type:Individual
Prefix:
First Name:PAOLO TRISTIAN
Middle Name:
Last Name:DOMINGO
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 1:1444 E BERMUDA DUNES ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-7103
Mailing Address - Country:US
Mailing Address - Phone:626-353-2507
Mailing Address - Fax:
Practice Address - Street 1:11080 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3047
Practice Address - Country:US
Practice Address - Phone:951-602-4120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-24
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist