Provider Demographics
NPI:1326411216
Name:LEWIS, IDA (PHARMD)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-2807
Mailing Address - Country:US
Mailing Address - Phone:510-339-8535
Mailing Address - Fax:510-339-8648
Practice Address - Street 1:2000 MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-2807
Practice Address - Country:US
Practice Address - Phone:510-339-8535
Practice Address - Fax:510-339-8648
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60379183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist