Provider Demographics
NPI:1417252586
Name:AI, TINA DIEM (PHARMD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:DIEM
Last Name:AI
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:AMBULATORY OUTPATIENT PHARMACY
Mailing Address - Street 2:3350 LA JOLLA VILLAGE DR
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92161-0001
Mailing Address - Country:US
Mailing Address - Phone:858-642-1669
Mailing Address - Fax:
Practice Address - Street 1:AMBULATORY OUTPATIENT PHARMACY
Practice Address - Street 2:3350 LA JOLLA VILLAGE DR
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0001
Practice Address - Country:US
Practice Address - Phone:858-642-1669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51457183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist