=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629675509
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHRINA KADIVAR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2020
-----------------------------------------------------
Last Update Date | 10/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13085 CENTRAL AVE STE 2
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-4184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-927-8323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11943 KIOWA AVE APT 1
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-940-0455
-----------------------------------------------------
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 | 83391
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------