Provider Demographics
NPI:1265233878
Name:NISHIMURA, TED (RPH)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:NISHIMURA
Suffix:
Gender:
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13592 SWEETSHADE WAY
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-8379
Mailing Address - Country:US
Mailing Address - Phone:714-975-4677
Mailing Address - Fax:
Practice Address - Street 1:1401 AVOCADO AVE STE 104
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8700
Practice Address - Country:US
Practice Address - Phone:949-640-1320
Practice Address - Fax:949-640-1324
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA361913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy