Provider Demographics
NPI:1336588151
Name:HERMOSILLA, KRISTY TAMORIA
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:TAMORIA
Last Name:HERMOSILLA
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 1:14629 7TH ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-4019
Mailing Address - Country:US
Mailing Address - Phone:760-245-6600
Mailing Address - Fax:760-245-1149
Practice Address - Street 1:14629 7TH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4019
Practice Address - Country:US
Practice Address - Phone:760-245-6600
Practice Address - Fax:760-245-1149
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65594183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist