Provider Demographics
NPI:1053763144
Name:JETAWATANA, SASIPAN
Entity type:Individual
Prefix:
First Name:SASIPAN
Middle Name:
Last Name:JETAWATANA
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 1:18350 ROSCOE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-4193
Mailing Address - Country:US
Mailing Address - Phone:818-885-7722
Mailing Address - Fax:
Practice Address - Street 1:18350 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4109
Practice Address - Country:US
Practice Address - Phone:818-688-5772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73148183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist