Healthcare Provider Details

I. General information

NPI: 1215002902
Provider Name (Legal Business Name): MARTIN KINSMAN VACCA PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 BELLEVUE RD
ATWATER CA
95301
US

IV. Provider business mailing address

6013 SPRING VALLEY CT
ATWATER CA
95301
US

V. Phone/Fax

Practice location:
  • Phone: 209-358-6306
  • Fax: 209-358-8639
Mailing address:
  • Phone: 209-357-1884
  • Fax: 209-358-8639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH 35524
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: