MEDICARE: EVA SUSI MULYAWATI RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RPH 58064	CA

General Provider Information

NPI Number	:	1285755751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVA SUSI MULYAWATI RPH

Provider Business Mailing Address
First Line	:	4127 MANDARIN TERRACE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-6054
Country	:	US
Telephone Number	:	619-659-1085
Fax Number	:	619-659-5738

Provider Business Practice Location Address
First Line	:	1665 ALPINE BOULEVARD
Second Line	:
City	:	ALPINE
State	:	CA
Zip	:	92101-3859
Country	:	US
Telephone Number	:	619-659-1085
Fax Number	:	619-659-5738

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	07/08/2007

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