Provider Demographics
NPI:1760751937
Name:SIU, MASON VAN (PHARM D)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:VAN
Last Name:SIU
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:VAN
Other - Middle Name:VI
Other - Last Name:TIEU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11900 BEACH BLVD
Mailing Address - Street 2:WALGREENS
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-3611
Mailing Address - Country:US
Mailing Address - Phone:714-890-9063
Mailing Address - Fax:714-890-9023
Practice Address - Street 1:11900 BEACH BLVD
Practice Address - Street 2:WALGREENS
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3611
Practice Address - Country:US
Practice Address - Phone:714-890-9063
Practice Address - Fax:714-890-9023
Is Sole Proprietor?:No
Enumeration Date:2011-12-18
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist