Healthcare Provider Details

I. General information

NPI: 1982375697
Provider Name (Legal Business Name): THOMAS DAVID IWAMOTO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 ROCKING W DR
BISHOP CA
93514-1995
US

IV. Provider business mailing address

1375 ROCKING W DR
BISHOP CA
93514-1995
US

V. Phone/Fax

Practice location:
  • Phone: 760-873-7883
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number85105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: