Provider Demographics
NPI:1588425979
Name:LANDOLT, MARY ANNA
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANNA
Last Name:LANDOLT
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 1:5015 CAPE MAY AVE UNIT 207
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-2570
Mailing Address - Country:US
Mailing Address - Phone:314-941-8748
Mailing Address - Fax:
Practice Address - Street 1:602 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-2207
Practice Address - Country:US
Practice Address - Phone:619-321-1614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89125183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist