Provider Demographics
NPI:1154668101
Name:KNOETZE, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KNOETZE
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 1:12475 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2143
Mailing Address - Country:US
Mailing Address - Phone:858-385-9235
Mailing Address - Fax:
Practice Address - Street 1:12475 RANCHO BERNARDO RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2143
Practice Address - Country:US
Practice Address - Phone:858-385-9235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54756183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist