Provider Demographics
NPI:1518699842
Name:FRIAS, LISSETTE YAEKO
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:YAEKO
Last Name:FRIAS
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 1:5044 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-2564
Mailing Address - Country:US
Mailing Address - Phone:626-586-9759
Mailing Address - Fax:
Practice Address - Street 1:1480 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3450
Practice Address - Country:US
Practice Address - Phone:909-593-2619
Practice Address - Fax:909-593-6789
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104604183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician