Provider Demographics
NPI:1124594395
Name:GERGIS, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:GERGIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6307 CHAROLAIS CT
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-3101
Mailing Address - Country:US
Mailing Address - Phone:909-747-7489
Mailing Address - Fax:
Practice Address - Street 1:1280 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-4686
Practice Address - Country:US
Practice Address - Phone:909-879-0305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA796901835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist