Provider Demographics
NPI:1508223124
Name:RICK, TY
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:
Last Name:RICK
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 1:3558 RUFFIN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2596
Mailing Address - Country:US
Mailing Address - Phone:858-627-5644
Mailing Address - Fax:
Practice Address - Street 1:3558 RUFFIN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2596
Practice Address - Country:US
Practice Address - Phone:858-627-5644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA490861835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0696050001Medicare PIN