Provider Demographics
NPI:1306309489
Name:MITRY, CHRISTINE (RPH)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:MITRY
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 1:105 FRESCO CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-4268
Mailing Address - Country:US
Mailing Address - Phone:925-690-7793
Mailing Address - Fax:
Practice Address - Street 1:6490 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:CA
Practice Address - Zip Code:94517-1153
Practice Address - Country:US
Practice Address - Phone:925-673-2803
Practice Address - Fax:925-673-5530
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA074740183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF8233082OtherCALIFORNIA DRIVERS LICENSE