Provider Demographics
NPI:1497264741
Name:ANTONIOUS, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:ANTONIOUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8191 REGENCY ST
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3325 S BRISTOL ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7245
Practice Address - Country:US
Practice Address - Phone:714-949-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74330183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA74330OtherCALIFORNIA BOARD OF PHARMACY