Provider Demographics
NPI:1376818963
Name:TSUMURA, MICHAEL TAKAO
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TAKAO
Last Name:TSUMURA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 E GLENARM ST APT 17
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-4278
Mailing Address - Country:US
Mailing Address - Phone:626-441-6190
Mailing Address - Fax:
Practice Address - Street 1:279 E GLENARM ST APT 17
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-4278
Practice Address - Country:US
Practice Address - Phone:626-441-6190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31790183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist