Provider Demographics
NPI:1497037170
Name:FAN-AGUTOS, RALNA
Entity Type:Individual
Prefix:
First Name:RALNA
Middle Name:
Last Name:FAN-AGUTOS
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 1:2800 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-7628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-7628
Practice Address - Country:US
Practice Address - Phone:925-443-6783
Practice Address - Fax:925-443-7225
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52019183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist