Provider Demographics
NPI:1396028718
Name:CUSTODIO-PANGILINAN, MA. ADRIANA T (RPH)
Entity Type:Individual
Prefix:
First Name:MA. ADRIANA
Middle Name:T
Last Name:CUSTODIO-PANGILINAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47900 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-2209
Mailing Address - Country:US
Mailing Address - Phone:760-771-1526
Mailing Address - Fax:760-771-1774
Practice Address - Street 1:47900 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-2209
Practice Address - Country:US
Practice Address - Phone:760-771-1526
Practice Address - Fax:760-771-1774
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA41606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist