Provider Demographics
NPI:1881288017
Name:RODRIGUEZ, ANTONETTE
Entity type:Individual
Prefix:
First Name:ANTONETTE
Middle Name:
Last Name:RODRIGUEZ
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 1:23900 IRONWOOD AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7151
Mailing Address - Country:US
Mailing Address - Phone:951-485-8100
Mailing Address - Fax:
Practice Address - Street 1:23900 IRONWOOD AVE STE C
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-7151
Practice Address - Country:US
Practice Address - Phone:951-485-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist