1043861313 NPI number — MARY GRACE P TRIAS PHARMACY TECHNICIAN

Table of content: MARY GRACE P TRIAS PHARMACY TECHNICIAN (NPI 1043861313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043861313 NPI number — MARY GRACE P TRIAS PHARMACY TECHNICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRIAS
Provider First Name:
MARY GRACE
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMACY TECHNICIAN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043861313
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31485 MANDY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE ELSINORE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92530-5124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-459-9017
Provider Business Mailing Address Fax Number:
951-245-8862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31485 MANDY CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE ELSINORE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92530-5124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-459-9017
Provider Business Practice Location Address Fax Number:
951-245-8862
Provider Enumeration Date:
09/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 376G00000X , with the licence number:  6048231740 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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