MEDICARE: JINA VINH DETTMAN

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	RPH52670	CA

General Provider Information

NPI Number	:	1538781505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JINA VINH DETTMAN

Provider Business Mailing Address
First Line	:	415 MOONEY DR APT C
Second Line	:
City	:	MONTEREY PARK
State	:	CA
Zip	:	91755-4124
Country	:	US
Telephone Number	:	626-202-6236
Fax Number	:

Provider Business Practice Location Address
First Line	:	1550 W MANCHESTER AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-5424
Country	:	US
Telephone Number	:	323-565-3101
Fax Number	:	323-565-3100

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

Provider Enumeration Date	:	05/13/2020
Last Update Date	:	05/13/2020

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