Provider Demographics
NPI:1932796844
Name:BOOZ, TEGAN
Entity Type:Individual
Prefix:
First Name:TEGAN
Middle Name:
Last Name:BOOZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 9TH AVE UNIT 608
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-4643
Mailing Address - Country:US
Mailing Address - Phone:913-787-3459
Mailing Address - Fax:
Practice Address - Street 1:4404 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-4310
Practice Address - Country:US
Practice Address - Phone:619-280-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-26
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83974183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist