Provider Demographics
NPI:1619258621
Name:TEDJA, LENNY (PHARMACY)
Entity Type:Individual
Prefix:
First Name:LENNY
Middle Name:
Last Name:TEDJA
Suffix:
Gender:F
Credentials:PHARMACY
Other - Prefix:
Other - First Name:SIU
Other - Middle Name:LIEN
Other - Last Name:THE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2141 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123-2708
Mailing Address - Country:US
Mailing Address - Phone:415-567-9320
Mailing Address - Fax:415-567-9162
Practice Address - Street 1:2141 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-2708
Practice Address - Country:US
Practice Address - Phone:415-567-9320
Practice Address - Fax:415-567-9162
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-03
Last Update Date:2011-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45795183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist