Healthcare Provider Details

I. General information

NPI: 1780930404
Provider Name (Legal Business Name): IDA RAGOJO SOMERA RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4774 WEST LANE APT 154
STOCKTON CA
95210
US

IV. Provider business mailing address

7620 N EL DORADO ST APT 154
STOCKTON CA
95207
US

V. Phone/Fax

Practice location:
  • Phone: 209-473-9170
  • Fax: 209-473-9174
Mailing address:
  • Phone: 209-478-1598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number65492
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: