=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396073680
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEONIE L TAN PHARM.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2009
-----------------------------------------------------
Last Update Date | 10/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3515 HARBOR BLVD
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92626-1437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-716-7771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3515 HARBOR BLVD
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92626-1437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-716-7771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 50355
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------