Provider Demographics
NPI:1316937675
Name:MISTRY, RAJ (RPH)
Entity type:Individual
Prefix:MR
First Name:RAJ
Middle Name:
Last Name:MISTRY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5830
Mailing Address - Country:US
Mailing Address - Phone:323-583-4307
Mailing Address - Fax:323-583-0900
Practice Address - Street 1:3180 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5830
Practice Address - Country:US
Practice Address - Phone:323-583-4307
Practice Address - Fax:323-583-0900
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH38454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARPH 38454OtherPHARMACIST
CAPHA344240Medicaid
CA1105960001Medicare NSC