Provider Demographics
NPI:1285363838
Name:MARTINEZ TIRADO, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:MARTINEZ TIRADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 CLARKE ST
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-2313
Mailing Address - Country:US
Mailing Address - Phone:760-768-4047
Mailing Address - Fax:
Practice Address - Street 1:211 W BIRCH ST
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-2348
Practice Address - Country:US
Practice Address - Phone:760-768-3169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATCH170818183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician