Provider Demographics
NPI:1548503378
Name:CORONEL, MYRNA LEAH (PHARMD)
Entity type:Individual
Prefix:
First Name:MYRNA LEAH
Middle Name:
Last Name:CORONEL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 SPRECKELS AVE
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-6005
Mailing Address - Country:US
Mailing Address - Phone:209-823-9982
Mailing Address - Fax:
Practice Address - Street 1:280 SPRECKELS AVE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-6005
Practice Address - Country:US
Practice Address - Phone:209-823-9982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA410215140OtherTAX ID