Healthcare Provider Details

I. General information

NPI: 1184974024
Provider Name (Legal Business Name): IGNACIA SUWANDI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3944 GRAND AVE T0912
CHINO CA
91710-5422
US

IV. Provider business mailing address

22942 ESTORIL DR UNIT 5
DIAMOND BAR CA
91765-4457
US

V. Phone/Fax

Practice location:
  • Phone: 909-465-5804
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number67518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: