Provider Demographics
NPI:1205351038
Name:MIZER, JACALYN (RPH)
Entity type:Individual
Prefix:
First Name:JACALYN
Middle Name:
Last Name:MIZER
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 1:132 DATE AVE APT A
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-2911
Practice Address - Country:US
Practice Address - Phone:619-213-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38589183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38589OtherREGISTERED PHARMACIST