Provider Demographics
NPI:1558680538
Name:PRUITT, THERESA KORBONSKI (RPH)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:KORBONSKI
Last Name:PRUITT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4649
Mailing Address - Country:US
Mailing Address - Phone:949-498-6752
Mailing Address - Fax:949-498-1779
Practice Address - Street 1:801 N EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4649
Practice Address - Country:US
Practice Address - Phone:949-498-6752
Practice Address - Fax:949-498-1779
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-31
Last Update Date:2010-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27567183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist