Provider Demographics
NPI:1689958258
Name:ANTONIO, CRISTINA DEPANTE
Entity Type:Individual
Prefix:
First Name:CRISTINA
Middle Name:DEPANTE
Last Name:ANTONIO
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 1:111 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-2629
Mailing Address - Country:US
Mailing Address - Phone:760-291-0299
Mailing Address - Fax:760-291-0212
Practice Address - Street 1:111 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-2629
Practice Address - Country:US
Practice Address - Phone:760-291-0299
Practice Address - Fax:760-291-0212
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53061183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist