Healthcare Provider Details

I. General information

NPI: 1467734004
Provider Name (Legal Business Name): RITA WIDJAJA RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21738 US HIGHWAY 18
APPLE VALLEY CA
92307
US

IV. Provider business mailing address

15153 VIA MARAVILLA
CHINO HILLS CA
91709-5030
US

V. Phone/Fax

Practice location:
  • Phone: 760-247-1840
  • Fax:
Mailing address:
  • Phone: 310-266-3586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60216
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: