Provider Demographics
NPI:1023424140
Name:ERDRICH, MARK (PHARMACIST)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ERDRICH
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:ERDRICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:2940 ABER ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-2424
Mailing Address - Country:US
Mailing Address - Phone:858-373-7856
Mailing Address - Fax:
Practice Address - Street 1:740 OTAY LAKES RD
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-6915
Practice Address - Country:US
Practice Address - Phone:858-373-7856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35327183500000X
NV8108183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist