Provider Demographics
NPI:1659648038
Name:TEDLA, MERON (RPH)
Entity Type:Individual
Prefix:
First Name:MERON
Middle Name:
Last Name:TEDLA
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 1:14100 BLOSSOM HILL RD
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-5118
Mailing Address - Country:US
Mailing Address - Phone:408-356-1152
Mailing Address - Fax:408-356-9352
Practice Address - Street 1:14100 BLOSSOM HILL RD
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-5118
Practice Address - Country:US
Practice Address - Phone:408-356-1152
Practice Address - Fax:408-356-9352
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA44835OtherPHARMACIST LICENSE