Provider Demographics
NPI:1710394846
Name:VAN, TOMY
Entity Type:Individual
Prefix:DR
First Name:TOMY
Middle Name:
Last Name:VAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 LEUCADIA BLVD
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2371
Mailing Address - Country:US
Mailing Address - Phone:760-634-9877
Mailing Address - Fax:
Practice Address - Street 1:1550 LEUCADIA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2371
Practice Address - Country:US
Practice Address - Phone:760-634-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist