=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437222866
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAVA GENEVIEVE HADIKUSUMO PHARM.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9310 SIERRA AVE
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92335-5711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-427-3838
-----------------------------------------------------
Fax | 909-427-3830
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9310 SIERRA AVE
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92335-5711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | RPH 57282
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------