Provider Demographics
NPI:1295006609
Name:LISTIAWAN, MARIO (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:LISTIAWAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 S 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-5718
Mailing Address - Country:US
Mailing Address - Phone:626-497-0303
Mailing Address - Fax:
Practice Address - Street 1:10811 INTERNATIONAL DR
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-7368
Practice Address - Country:US
Practice Address - Phone:916-503-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65574183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist