Healthcare Provider Details

I. General information

NPI: 1144529330
Provider Name (Legal Business Name): MR. ALLEN OVIEMUNO ICHIDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 03/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3795 W SHIELDS AVE
FRESNO CA
93722-5247
US

IV. Provider business mailing address

3795 W SHIELDS AVE
FRESNO CA
93722-5247
US

V. Phone/Fax

Practice location:
  • Phone: 559-271-5030
  • Fax: 559-271-5041
Mailing address:
  • Phone: 559-271-5030
  • Fax: 559-271-5041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number63478
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: