Provider Demographics
NPI:1730664293
Name:FORMELLA, ANDREA ELLEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:ELLEN
Last Name:FORMELLA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:ANDREA
Other - Middle Name:ELLEN
Other - Last Name:EGGERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:28652 MALABAR RD
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-1622
Mailing Address - Country:US
Mailing Address - Phone:512-796-7547
Mailing Address - Fax:
Practice Address - Street 1:28652 MALABAR RD
Practice Address - Street 2:
Practice Address - City:TRABUCO CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679-1622
Practice Address - Country:US
Practice Address - Phone:512-796-7547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11223-40183500000X, 1835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
No183500000XPharmacy Service ProvidersPharmacist