Provider Demographics
NPI:1285755751
Name:MULYAWATI, EVA SUSI (RPH)
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:SUSI
Last Name:MULYAWATI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4127 MANDARIN TERRACE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-6054
Mailing Address - Country:US
Mailing Address - Phone:619-659-1085
Mailing Address - Fax:619-659-5738
Practice Address - Street 1:1665 ALPINE BOULEVARD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:92101-3859
Practice Address - Country:US
Practice Address - Phone:619-659-1085
Practice Address - Fax:619-659-5738
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 58064183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist