Healthcare Provider Details

I. General information

NPI: 1679832331
Provider Name (Legal Business Name): MICHAEL JOHN GIOVANNONI PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 HWY 104 ---- MULE CREEK STATE PRISON
IONE CA
95640
US

IV. Provider business mailing address

2051 OLIVIA WAY
STOCKTON CA
95209-4528
US

V. Phone/Fax

Practice location:
  • Phone: 209-274-4911
  • Fax:
Mailing address:
  • Phone: 209-951-7485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH 31107
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: