Healthcare Provider Details

I. General information

NPI: 1891016184
Provider Name (Legal Business Name): BANN ABOUDI ALLYAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 S ARCHIBALD AVE
ONTARIO CA
91761-7918
US

IV. Provider business mailing address

3000 S ARCHIBALD AVE
ONTARIO CA
91761-7918
US

V. Phone/Fax

Practice location:
  • Phone: 909-773-0073
  • Fax: 909-773-0158
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number48649
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13348
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: