Provider Demographics
NPI:1114212495
Name:PROBST, JOHN WESLEY (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WESLEY
Last Name:PROBST
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 1:1200 N SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5104
Mailing Address - Country:US
Mailing Address - Phone:310-546-1731
Mailing Address - Fax:310-546-1731
Practice Address - Street 1:1200 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5104
Practice Address - Country:US
Practice Address - Phone:310-546-1731
Practice Address - Fax:310-546-1731
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist