Provider Demographics
NPI:1952949109
Name:EDUSADA, NOVA
Entity Type:Individual
Prefix:
First Name:NOVA
Middle Name:
Last Name:EDUSADA
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:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92564-0070
Mailing Address - Country:US
Mailing Address - Phone:562-242-6967
Mailing Address - Fax:
Practice Address - Street 1:26973 NEWPORT RD
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-9221
Practice Address - Country:US
Practice Address - Phone:562-242-6967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81577183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist