Provider Demographics
NPI:1336671718
Name:BAUTISTA, SASHA D
Entity Type:Individual
Prefix:
First Name:SASHA
Middle Name:D
Last Name:BAUTISTA
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 1:12874 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-4540
Mailing Address - Country:US
Mailing Address - Phone:562-567-6933
Mailing Address - Fax:562-944-2710
Practice Address - Street 1:12874 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-4540
Practice Address - Country:US
Practice Address - Phone:562-567-6933
Practice Address - Fax:562-944-2710
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43241183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician