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General NPI Number Information
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NPI Number | 1346849239
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Entity Type | Individual
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Provider Name | TATIANA JENISTOVA
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Gender | Female
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Dates
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Enumeration Date | 10/21/2020
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Last Update Date | 10/21/2020
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Provider Practice Location Address
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Address Line | 42520 BOB HOPE DR
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-4471
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Country | US
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Telephone | 760-568-5651
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Fax |
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Provider Business Mailing Address
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Address Line | 234 CLIFF DR APT 10
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City | LAGUNA BEACH
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State | CA
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Zip | 92651-4305
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Country | US
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Telephone | 175-782-2972
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 82106
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License Number State | CA
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