Provider Demographics
NPI:1093082067
Name:CRIVELLO, TINA (RPH)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:CRIVELLO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 FREMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-5712
Mailing Address - Country:US
Mailing Address - Phone:831-393-9231
Mailing Address - Fax:831-393-9409
Practice Address - Street 1:1055 FREMONT BLVD
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-5712
Practice Address - Country:US
Practice Address - Phone:831-393-9231
Practice Address - Fax:831-393-9409
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist