Healthcare Provider Details

I. General information

NPI: 1598171076
Provider Name (Legal Business Name): ALLEN RANGSISOURIGNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 ROBINSON AVE
SAN DIEGO CA
92103-4209
US

IV. Provider business mailing address

819 S 44TH ST
SAN DIEGO CA
92113-2904
US

V. Phone/Fax

Practice location:
  • Phone: 619-291-3705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number70286
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: