Healthcare Provider Details

I. General information

NPI: 1225502529
Provider Name (Legal Business Name): CAROLINE ENYINNAYA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2019
Last Update Date: 01/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 W HARDING WAY
STOCKTON CA
95204-5716
US

IV. Provider business mailing address

1530 TIMBERLAKE CIR
LODI CA
95242-4271
US

V. Phone/Fax

Practice location:
  • Phone: 209-941-9632
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number80117
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: