Provider Demographics
NPI:1194001768
Name:CANNISTRACI, PAULA LYNN (PHARMD)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:LYNN
Last Name:CANNISTRACI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MCHENRY AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5439
Mailing Address - Country:US
Mailing Address - Phone:209-577-8695
Mailing Address - Fax:209-577-2916
Practice Address - Street 1:1101 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5439
Practice Address - Country:US
Practice Address - Phone:209-577-8695
Practice Address - Fax:209-577-4570
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57581183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist