Provider Demographics
NPI:1790211688
Name:KORT, MARY QUSTANDI (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:QUSTANDI
Last Name:KORT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15684 CANON LN
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5244
Mailing Address - Country:US
Mailing Address - Phone:714-936-6171
Mailing Address - Fax:
Practice Address - Street 1:15684 CANON LN
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5244
Practice Address - Country:US
Practice Address - Phone:714-936-6171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56208183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist