Healthcare Provider Details

I. General information

NPI: 1316473135
Provider Name (Legal Business Name): DOMINIQUE DEBOLD PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6247 GRAHAM HILL RD
FELTON CA
95018-9723
US

IV. Provider business mailing address

680 COLLEEN DR
SAN JOSE CA
95123-5512
US

V. Phone/Fax

Practice location:
  • Phone: 831-335-6403
  • Fax:
Mailing address:
  • Phone: 415-894-0128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number76191
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: