Healthcare Provider Details

I. General information

NPI: 1649852161
Provider Name (Legal Business Name): ANTHONY JEROME SOLOMON CUISON INTERN PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 04/23/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

IV. Provider business mailing address

4773 S ROGERS WAY
ONTARIO CA
91762-4395
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 925-354-1093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number43033
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: