Provider Demographics
NPI:1972663631
Name:BAUTISTA, JENNIGRACE (PHARM D)
Entity type:Individual
Prefix:
First Name:JENNIGRACE
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 SURREYGLEN WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-5611
Mailing Address - Country:US
Mailing Address - Phone:619-246-4288
Mailing Address - Fax:
Practice Address - Street 1:10990 SAN DIEGO MISSION RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2417
Practice Address - Country:US
Practice Address - Phone:619-641-4291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55747183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist