Provider Demographics
NPI:1336035252
Name:HUERTA ELLAZAR, TERESITA
Entity type:Individual
Prefix:
First Name:TERESITA
Middle Name:
Last Name:HUERTA ELLAZAR
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 1:9025 CAPRICORN WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4711
Mailing Address - Country:US
Mailing Address - Phone:619-672-4353
Mailing Address - Fax:
Practice Address - Street 1:740 W ALLUVIAL AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-5509
Practice Address - Country:US
Practice Address - Phone:800-797-3543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90860183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist