Provider Demographics
NPI:1336581081
Name:ORTIZ, GRACE (RPH)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:ORTIZ
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 1:25900 IRIS AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-1655
Mailing Address - Country:US
Mailing Address - Phone:951-243-1234
Mailing Address - Fax:951-243-7900
Practice Address - Street 1:25900 IRIS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-1655
Practice Address - Country:US
Practice Address - Phone:951-243-1234
Practice Address - Fax:951-243-7900
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist