Provider Demographics
NPI:1558901017
Name:BAUTISTA, JUNELYN BANTAD
Entity Type:Individual
Prefix:
First Name:JUNELYN
Middle Name:BANTAD
Last Name:BAUTISTA
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 1:912 E 222ND ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3402
Mailing Address - Country:US
Mailing Address - Phone:310-989-6140
Mailing Address - Fax:
Practice Address - Street 1:6226 E SPRING ST STE 140
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-1441
Practice Address - Country:US
Practice Address - Phone:562-420-1303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81565183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist