Healthcare Provider Details

I. General information

NPI: 1972024073
Provider Name (Legal Business Name): PHILLIP HIVALE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11227 SAN MATEO DR APT A
LOMA LINDA CA
92354-3274
US

IV. Provider business mailing address

11227 SAN MATEO DR APT A
LOMA LINDA CA
92354-3274
US

V. Phone/Fax

Practice location:
  • Phone: 817-797-1254
  • Fax:
Mailing address:
  • Phone: 817-797-1254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number68618
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: