Provider Demographics
NPI:1134448319
Name:KUSWANTO, FETTY (PHARMD)
Entity type:Individual
Prefix:
First Name:FETTY
Middle Name:
Last Name:KUSWANTO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-7774
Mailing Address - Country:US
Mailing Address - Phone:714-538-3382
Mailing Address - Fax:714-538-4152
Practice Address - Street 1:1825 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-7774
Practice Address - Country:US
Practice Address - Phone:714-538-3382
Practice Address - Fax:714-538-4152
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 31587183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist