Provider Demographics
NPI:1497865570
Name:SANTOS, TEODORO REYES
Entity Type:Individual
Prefix:MR
First Name:TEODORO
Middle Name:REYES
Last Name:SANTOS
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 1:1663 BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-5710
Mailing Address - Country:US
Mailing Address - Phone:213-250-7229
Mailing Address - Fax:213-250-0439
Practice Address - Street 1:1663 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5710
Practice Address - Country:US
Practice Address - Phone:213-250-7229
Practice Address - Fax:213-250-0439
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31852183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05-73445OtherNABP NUMBER
CAPHY229000Medicaid