Provider Demographics
NPI:1124898366
Name:SURJADINATA, ABRAHAM (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ABRAHAM
Middle Name:
Last Name:SURJADINATA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18340 YORBA LINDA BLVD # 107-128
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-4058
Mailing Address - Country:US
Mailing Address - Phone:626-384-1346
Mailing Address - Fax:
Practice Address - Street 1:18340 YORBA LINDA BLVD # 107-128
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-4058
Practice Address - Country:US
Practice Address - Phone:626-384-1346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty