Provider Demographics
NPI:1831678762
Name:HIEDO, RENA
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:
Last Name:HIEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3749 AVOCADO BLVD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7301
Mailing Address - Country:US
Mailing Address - Phone:619-760-5335
Mailing Address - Fax:619-670-0159
Practice Address - Street 1:3749 AVOCADO BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7301
Practice Address - Country:US
Practice Address - Phone:619-760-5335
Practice Address - Fax:619-670-0159
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77028183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist