Provider Demographics
NPI:1417504390
Name:LICOP, ANGELICA KRISTINE AGUSTIN (RPH)
Entity Type:Individual
Prefix:
First Name:ANGELICA KRISTINE
Middle Name:AGUSTIN
Last Name:LICOP
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 ORANGETHORPE AVE APT 4401
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1236
Mailing Address - Country:US
Mailing Address - Phone:949-903-8450
Mailing Address - Fax:
Practice Address - Street 1:5600 ORANGETHORPE AVE APT 4401
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1236
Practice Address - Country:US
Practice Address - Phone:949-903-8450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80659183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist