Provider Demographics
NPI:1396413415
Name:KANETAKE, SIERRA MAY
Entity Type:Individual
Prefix:
First Name:SIERRA
Middle Name:MAY
Last Name:KANETAKE
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 1:5055 73RD ST APT 73
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-1858
Mailing Address - Country:US
Mailing Address - Phone:408-656-6739
Mailing Address - Fax:
Practice Address - Street 1:550 WASHINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2227
Practice Address - Country:US
Practice Address - Phone:858-964-1014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH84233183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARPH84233OtherREGISTERED PHARMACIST LICENSE