Healthcare Provider Details

I. General information

NPI: 1760933717
Provider Name (Legal Business Name): SUSAN IWAMOTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 J ST
SACRAMENTO CA
95819-2605
US

IV. Provider business mailing address

6000 J ST
SACRAMENTO CA
95819-2605
US

V. Phone/Fax

Practice location:
  • Phone: 916-278-6040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number32840
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: