Provider Demographics
NPI:1558422535
Name:SMITH, FORREST DALE (RPH, MS)
Entity type:Individual
Prefix:
First Name:FORREST
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4675 GLACIER AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2552
Mailing Address - Country:US
Mailing Address - Phone:619-282-8112
Mailing Address - Fax:
Practice Address - Street 1:4647 ZION AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-2507
Practice Address - Country:US
Practice Address - Phone:619-528-3038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40751183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist