Provider Demographics
NPI:1497104749
Name:IBANEZ, MYRNA
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:IBANEZ
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 1:222 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1217
Mailing Address - Country:US
Mailing Address - Phone:310-671-2386
Mailing Address - Fax:310-671-5841
Practice Address - Street 1:222 N MARKET ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1217
Practice Address - Country:US
Practice Address - Phone:310-671-2386
Practice Address - Fax:310-671-5841
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 432121835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care