Provider Demographics
NPI:1417222340
Name:BLACK, ANDREW PATRICK (RPH)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:PATRICK
Last Name:BLACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79795 HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-4756
Mailing Address - Country:US
Mailing Address - Phone:760-342-0656
Mailing Address - Fax:
Practice Address - Street 1:79795 HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-4756
Practice Address - Country:US
Practice Address - Phone:760-342-0656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-10
Last Update Date:2012-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist