Healthcare Provider Details

I. General information

NPI: 1912608563
Provider Name (Legal Business Name): OLIVEA DEGRANDE-EQUIHUA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17055 VAN BUREN BLVD
RIVERSIDE CA
92504-5923
US

IV. Provider business mailing address

3248 MOHAWK TRL
RIVERSIDE CA
92503-5458
US

V. Phone/Fax

Practice location:
  • Phone: 951-780-3343
  • Fax:
Mailing address:
  • Phone: 951-742-9829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number109929
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: