Provider Demographics
NPI:1154642692
Name:SIU, ANNIE TIFFANY
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:TIFFANY
Last Name:SIU
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 1:3141 EAST COAST HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625
Mailing Address - Country:US
Mailing Address - Phone:949-675-0414
Mailing Address - Fax:
Practice Address - Street 1:3141 E COAST HWY
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2330
Practice Address - Country:US
Practice Address - Phone:949-675-0414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46552183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist