Healthcare Provider Details

I. General information

NPI: 1629559133
Provider Name (Legal Business Name): PANATHDA VICTORIA BAYRASY PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 11/15/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MARK WEST SPRINGS RD
SANTA ROSA CA
95403-1436
US

IV. Provider business mailing address

30 MARK WEST SPRINGS RD
SANTA ROSA CA
95403-1436
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-4340
  • Fax:
Mailing address:
  • Phone: 707-576-4340
  • Fax: 707-573-5455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number78785
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: