Healthcare Provider Details

I. General information

NPI: 1518699842
Provider Name (Legal Business Name): LISSETTE YAEKO FRIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 FOOTHILL BLVD
LA VERNE CA
91750-3450
US

IV. Provider business mailing address

5044 WALNUT AVE
CHINO CA
91710-2564
US

V. Phone/Fax

Practice location:
  • Phone: 909-593-2619
  • Fax: 909-593-6789
Mailing address:
  • Phone: 626-586-9759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number104604
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: