Provider Demographics
NPI:1225618465
Name:MTTA, KIROLLOS
Entity Type:Individual
Prefix:
First Name:KIROLLOS
Middle Name:
Last Name:MTTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6741 LINCOLN AVE # SPAC170
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-4167
Mailing Address - Country:US
Mailing Address - Phone:657-262-5471
Mailing Address - Fax:
Practice Address - Street 1:9194 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3872
Practice Address - Country:US
Practice Address - Phone:951-977-8667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist