Provider Demographics
NPI:1407133093
Name:GANDHI, POONAM JITEN
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:JITEN
Last Name:GANDHI
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 1:1330 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-8500
Mailing Address - Country:US
Mailing Address - Phone:714-403-1947
Mailing Address - Fax:
Practice Address - Street 1:1330 E 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8500
Practice Address - Country:US
Practice Address - Phone:714-547-1042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65670183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist