Provider Demographics
NPI:1407564313
Name:FANOUS, CHRISTIE NADENE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIE
Middle Name:NADENE
Last Name:FANOUS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22712 WHITE LILY CIR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-6020
Mailing Address - Country:US
Mailing Address - Phone:951-902-9476
Mailing Address - Fax:
Practice Address - Street 1:30736 BENTON RD
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:CA
Practice Address - Zip Code:92596-8466
Practice Address - Country:US
Practice Address - Phone:951-902-9476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86889183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist