Organization
MACTOR, INC.
Active
Other names
Provision Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
MITESH PATEL PHARM D (CEO)
(619) 466-3246
Entity
Organization
Contact information
Practice address
4428 GLACIER AVE, SAN DIEGO, CA 92120-3304
(619) 466-3246
(619) 466-4134
Mailing address
11676 TREADWELL DR, POWAY, CA 92064
(619) 466-3246
(619) 466-4134
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
56091
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0534342
NCPDP
—
05
—
PHA466130
—
CA
Enumeration date
07/10/2006
Last updated
03/04/2020
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