Provider Demographics
NPI:1104360288
Name:PROMLAP, JOHN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PROMLAP
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 HARE AVE
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-3928
Mailing Address - Country:US
Mailing Address - Phone:949-394-8791
Mailing Address - Fax:
Practice Address - Street 1:1800 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2329
Practice Address - Country:US
Practice Address - Phone:702-383-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV19349183500000X
CA76041183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist