Provider Demographics
NPI:1669082368
Name:CHRISTUDAS, MINI JOHNSON
Entity type:Individual
Prefix:
First Name:MINI
Middle Name:JOHNSON
Last Name:CHRISTUDAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 E ORANGEWOOD AVE APT C225
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-4478
Mailing Address - Country:US
Mailing Address - Phone:714-706-2209
Mailing Address - Fax:
Practice Address - Street 1:27818 CLINTON KEITH RD
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-8554
Practice Address - Country:US
Practice Address - Phone:951-704-1124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA823881835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory CareGroup - Single Specialty