Provider Demographics
NPI:1053842401
Name:SIM, JILL KRISTIE BANDALAN
Entity Type:Individual
Prefix:
First Name:JILL KRISTIE
Middle Name:BANDALAN
Last Name:SIM
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 1:3430 E LA PALMA AVE
Mailing Address - Street 2:BLDG 2 FLR 1
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-2020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3430 E LA PALMA AVE
Practice Address - Street 2:BLDG 2 FLR 1
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2020
Practice Address - Country:US
Practice Address - Phone:714-644-7180
Practice Address - Fax:714-644-7183
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59725183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist