Basic Information
| Provider Information | |||||||||
| NPI: | 1174178602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOEBIANTO | ||||||||
| FirstName: | TARAH | ||||||||
| MiddleName: | JANEA | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1651 COUNTRY CLUB DR | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912082038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183917457 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 249 E POMONA BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTEREY PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917557237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884999303 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2019 | ||||||||
| LastUpdateDate: | 08/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 64502 | CA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.