Provider Demographics
NPI:1093097750
Name:RUSTAMOVA, INGA
Entity Type:Individual
Prefix:
First Name:INGA
Middle Name:
Last Name:RUSTAMOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:INGA
Other - Middle Name:
Other - Last Name:KANTOROV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1916 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501
Mailing Address - Country:US
Mailing Address - Phone:510-864-2800
Mailing Address - Fax:510-864-2869
Practice Address - Street 1:1916 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501
Practice Address - Country:US
Practice Address - Phone:510-864-2800
Practice Address - Fax:510-864-2869
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist