Provider Demographics
NPI:1396413217
Name:ESTRADA, MAYRA
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:ESTRADA
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 1:15425 WASHOAN RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-3261
Mailing Address - Country:US
Mailing Address - Phone:323-812-2554
Mailing Address - Fax:
Practice Address - Street 1:13720 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-8713
Practice Address - Country:US
Practice Address - Phone:760-955-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35703183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician