Provider Demographics
NPI:1447676515
Name:TOM, ERNEST JR
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:TOM
Suffix:JR
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 1:1745 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4923
Mailing Address - Country:US
Mailing Address - Phone:626-799-2926
Mailing Address - Fax:626-799-2183
Practice Address - Street 1:1745 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4923
Practice Address - Country:US
Practice Address - Phone:626-799-2926
Practice Address - Fax:626-799-2183
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA51194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist