Provider Demographics
NPI:1053802314
Name:RUSKOVA, LIDIJA (RPH)
Entity type:Individual
Prefix:
First Name:LIDIJA
Middle Name:
Last Name:RUSKOVA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3362 WATERMARKE PL
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-5618
Mailing Address - Country:US
Mailing Address - Phone:949-378-6335
Mailing Address - Fax:
Practice Address - Street 1:244 FOREST AVE
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2114
Practice Address - Country:US
Practice Address - Phone:949-494-1059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73682183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist