Provider Demographics
NPI:1093402695
Name:VIDAURRAZAGA, LUIS ANTONIO JR
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ANTONIO
Last Name:VIDAURRAZAGA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12049 PENFORD DR
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1546
Mailing Address - Country:US
Mailing Address - Phone:310-908-5817
Mailing Address - Fax:
Practice Address - Street 1:12049 PENFORD DR
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1546
Practice Address - Country:US
Practice Address - Phone:310-908-5817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAINT44785183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist