Provider Demographics
NPI:1811575699
Name:IWU, TONIE
Entity Type:Individual
Prefix:
First Name:TONIE
Middle Name:
Last Name:IWU
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 1:565 W CORAZON WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:95391-2050
Mailing Address - Country:US
Mailing Address - Phone:510-754-3476
Mailing Address - Fax:
Practice Address - Street 1:3010 W GRANT LINE RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95304-9402
Practice Address - Country:US
Practice Address - Phone:209-836-5786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist