Provider Demographics
NPI:1609756881
Name:SAN AGUSTIN, MARIA CHRISTINE TANAWAN
Entity type:Individual
Prefix:
First Name:MARIA CHRISTINE
Middle Name:TANAWAN
Last Name:SAN AGUSTIN
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 1:985 EVERGREEN CIR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3679
Mailing Address - Country:US
Mailing Address - Phone:626-820-5800
Mailing Address - Fax:626-330-7901
Practice Address - Street 1:16666 E JOHNSON DR
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91745-2412
Practice Address - Country:US
Practice Address - Phone:626-820-5800
Practice Address - Fax:626-330-7901
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-06
Last Update Date:2025-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68782183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty