Provider Demographics
NPI:1407513229
Name:SUMI MAMMEN, ANNAMMA
Entity Type:Individual
Prefix:MS
First Name:ANNAMMA
Middle Name:
Last Name:SUMI MAMMEN
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 1:3320 NORTH TRACY BLVD, CALIFORNIA .US.95376
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376
Mailing Address - Country:US
Mailing Address - Phone:209-836-2316
Mailing Address - Fax:
Practice Address - Street 1:3320 N TRACY BLVD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-1796
Practice Address - Country:US
Practice Address - Phone:209-836-2316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84470183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist