Provider Demographics
NPI:1689113029
Name:PATTYNAMA, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:PATTYNAMA
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 1:9985 SIERRA AVE
Mailing Address - Street 2:LINK PHARMACY 2 FLOOR
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6720
Mailing Address - Country:US
Mailing Address - Phone:909-427-6583
Mailing Address - Fax:
Practice Address - Street 1:9985 SIERRA AVE
Practice Address - Street 2:LINK PHARMACY 2 FLOOR
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-6583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist