Provider Demographics
NPI:1295018513
Name:BALLESTEROS, LALA (RPH)
Entity Type:Individual
Prefix:
First Name:LALA
Middle Name:
Last Name:BALLESTEROS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 ELK GROVE FLORIN RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-1609
Mailing Address - Country:US
Mailing Address - Phone:916-687-3251
Mailing Address - Fax:916-687-3289
Practice Address - Street 1:9200 ELK GROVE FLORIN RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1609
Practice Address - Country:US
Practice Address - Phone:916-687-3251
Practice Address - Fax:916-687-3289
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63991183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist