Healthcare Provider Details

I. General information

NPI: 1174113195
Provider Name (Legal Business Name): ALYSON CORNELIUS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2021
Last Update Date: 01/23/2021
Certification Date: 01/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4424 BLUFF CREEK DR
MODESTO CA
95355-9105
US

IV. Provider business mailing address

4424 BLUFF CREEK DR
MODESTO CA
95355-9105
US

V. Phone/Fax

Practice location:
  • Phone: 707-382-6226
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number67262
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number67262
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: