Healthcare Provider Details

I. General information

NPI: 1013902113
Provider Name (Legal Business Name): RON JENNISON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 SPANOS CT STE 105
MODESTO CA
95355-2810
US

IV. Provider business mailing address

1401 SPANOS CT STE 105
MODESTO CA
95355-2810
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-3141
  • Fax: 209-571-9538
Mailing address:
  • Phone: 209-525-3141
  • Fax: 209-571-9538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0859760001
License Number StateCA

VIII. Authorized Official

Name: MR. RONALD JENNISON
Title or Position: OWNER PHARMACIST
Credential:
Phone: 209-525-3141