Provider Demographics
NPI:1407411036
Name:SEO, PRISCILLA
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:SEO
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 1:9538 ANACONDA AVE
Mailing Address - Street 2:
Mailing Address - City:OAK HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92344-0556
Mailing Address - Country:US
Mailing Address - Phone:213-258-7180
Mailing Address - Fax:
Practice Address - Street 1:2150 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-1605
Practice Address - Country:US
Practice Address - Phone:760-337-1603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH79931183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist