Provider Demographics
NPI:1205108602
Name:TAK, LAWRENCE EUGENE (RPH)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:EUGENE
Last Name:TAK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:EUGENE
Other - Middle Name:LAWRENCE
Other - Last Name:TAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:30530 RANCHO CALIFORNIA RD
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-3277
Mailing Address - Country:US
Mailing Address - Phone:951-694-0055
Mailing Address - Fax:951-694-5645
Practice Address - Street 1:30530 RANCHO CALIFORNIA RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-3277
Practice Address - Country:US
Practice Address - Phone:951-699-7230
Practice Address - Fax:951-694-5645
Is Sole Proprietor?:No
Enumeration Date:2012-01-31
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55398183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist