Provider Demographics
NPI:1548982861
Name:PEN, SIHANEAT
Entity type:Individual
Prefix:
First Name:SIHANEAT
Middle Name:
Last Name:PEN
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 1:18438 VANTAGE POINTE DR
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-5142
Mailing Address - Country:US
Mailing Address - Phone:562-833-7856
Mailing Address - Fax:
Practice Address - Street 1:4400 E LOS COYOTES DIAGONAL
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-2819
Practice Address - Country:US
Practice Address - Phone:562-833-7856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD8055282OtherDRIVER LICENSE