Healthcare Provider Details

I. General information

NPI: 1689376527
Provider Name (Legal Business Name): KIMBERLY STURDIVANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 NORTHGATE MALL
SAN RAFAEL CA
94903-3671
US

IV. Provider business mailing address

133 SKYWAY DR
VALLEJO CA
94591-4026
US

V. Phone/Fax

Practice location:
  • Phone: 415-492-0888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number87667
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: