Provider Demographics
NPI:1801399951
Name:TOLENTINO, LYDDA SANTIAGO (RPH)
Entity Type:Individual
Prefix:
First Name:LYDDA
Middle Name:SANTIAGO
Last Name:TOLENTINO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4555 THORNTON AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-5641
Mailing Address - Country:US
Mailing Address - Phone:408-421-3597
Mailing Address - Fax:
Practice Address - Street 1:7700 EDGEWATER DR
Practice Address - Street 2:220
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94621
Practice Address - Country:US
Practice Address - Phone:510-878-7562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68965183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist