Healthcare Provider Details

I. General information

NPI: 1992875470
Provider Name (Legal Business Name): NAHOKO AZETA PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BICENTENNIAL WAY
SANTA ROSA CA
95403-2149
US

IV. Provider business mailing address

2952 BAY VILLAGE CIR APT 2065
SANTA ROSA CA
95403-3625
US

V. Phone/Fax

Practice location:
  • Phone: 707-571-3287
  • Fax: 707-571-4518
Mailing address:
  • Phone: 619-948-4754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberRPH 56245
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: