Provider Demographics
NPI:1336512706
Name:VARGESE, JEENA
Entity Type:Individual
Prefix:
First Name:JEENA
Middle Name:
Last Name:VARGESE
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:B-4 SILVER HOMES
Mailing Address - Street 2:VAZHAKKALA PO
Mailing Address - City:KAKKANAD
Mailing Address - State:KERALA
Mailing Address - Zip Code:695103
Mailing Address - Country:IN
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4440 ALAMO ST
Practice Address - Street 2:4440 ALAMO ST
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-1733
Practice Address - Country:US
Practice Address - Phone:805-522-3120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-07
Last Update Date:2015-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69577183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist