Provider Demographics
NPI:1013668334
Name:FUENTES, CYD CHARISSE DIONALDO (RPH)
Entity Type:Individual
Prefix:
First Name:CYD CHARISSE
Middle Name:DIONALDO
Last Name:FUENTES
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 1:8668 SCARLET SAGE WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-3853
Mailing Address - Country:US
Mailing Address - Phone:916-996-3273
Mailing Address - Fax:
Practice Address - Street 1:5100 LAGUNA BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-4159
Practice Address - Country:US
Practice Address - Phone:916-684-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH85517183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist