Provider Demographics
NPI:1184974024
Name:SUWANDI, IGNACIA
Entity type:Individual
Prefix:
First Name:IGNACIA
Middle Name:
Last Name:SUWANDI
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 1:22942 ESTORIL DR UNIT 5
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3944 GRAND AVE
Practice Address - Street 2:T0912
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-5422
Practice Address - Country:US
Practice Address - Phone:909-465-5804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67518183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist