Provider Demographics
NPI:1528413168
Name:JOHN, JAYA
Entity Type:Individual
Prefix:
First Name:JAYA
Middle Name:
Last Name:JOHN
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 1:1875 N KRAEMER BLVD
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-2616
Mailing Address - Country:US
Mailing Address - Phone:714-572-5656
Mailing Address - Fax:714-572-5662
Practice Address - Street 1:1875 N KRAEMER BLVD
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-2616
Practice Address - Country:US
Practice Address - Phone:714-572-5656
Practice Address - Fax:714-572-5662
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist