Provider Demographics
NPI:1538781505
Name:DETTMAN, JINA VINH
Entity type:Individual
Prefix:
First Name:JINA
Middle Name:VINH
Last Name:DETTMAN
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 1:415 MOONEY DR APT C
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91755-4124
Mailing Address - Country:US
Mailing Address - Phone:626-202-6236
Mailing Address - Fax:
Practice Address - Street 1:1550 W MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-5424
Practice Address - Country:US
Practice Address - Phone:323-565-3101
Practice Address - Fax:323-565-3100
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH526701835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty