Healthcare Provider Details

I. General information

NPI: 1083954283
Provider Name (Legal Business Name): MISS REBECCA WITTENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2013
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 STOCKTON BLVD
SACRAMENTO CA
95817-2201
US

IV. Provider business mailing address

1600 H ST APT 317
SACRAMENTO CA
95814-2014
US

V. Phone/Fax

Practice location:
  • Phone: 626-862-5509
  • Fax:
Mailing address:
  • Phone: 626-862-5509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number851859
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: