Healthcare Provider Details

I. General information

NPI: 1750543302
Provider Name (Legal Business Name): TECIA RYAN, PHARM.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 MILVIA ST
BERKELEY CA
94704-2605
US

IV. Provider business mailing address

2515 MILVIA ST
BERKELEY CA
94704-2605
US

V. Phone/Fax

Practice location:
  • Phone: 510-385-5094
  • Fax: 510-981-1678
Mailing address:
  • Phone: 510-385-5094
  • Fax: 510-981-1678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License Number27261
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number27261
License Number StateCA

VIII. Authorized Official

Name: DR. TECIA GAIL RYAN
Title or Position: CEO, CFO, SOLE STOCKHOLDER
Credential: PHARM.D.
Phone: 510-385-5094