Provider Demographics
NPI:1376912543
Name:MANTARA, RUZLY (PHARMD)
Entity Type:Individual
Prefix:
First Name:RUZLY
Middle Name:
Last Name:MANTARA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 E CHAPARRAL ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-9158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5918 STONERIDGE MALL RD
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-3229
Practice Address - Country:US
Practice Address - Phone:925-467-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73154183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist