Healthcare Provider Details

I. General information

NPI: 1689497042
Provider Name (Legal Business Name): VANESSA CONNOLLY PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

397 5TH ST
GUSTINE CA
95322-1236
US

IV. Provider business mailing address

537 FLOUR MILL DR
NEWMAN CA
95360-9652
US

V. Phone/Fax

Practice location:
  • Phone: 208-854-1007
  • Fax:
Mailing address:
  • Phone: 209-535-7449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH89697
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: