Provider Demographics
NPI:1073850699
Name:LOYOLA, GRACE
Entity Type:Individual
Prefix:MISS
First Name:GRACE
Middle Name:
Last Name:LOYOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 ROHNERT PARK EXPY W
Mailing Address - Street 2:UNIT 341
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-7962
Mailing Address - Country:US
Mailing Address - Phone:916-534-0232
Mailing Address - Fax:
Practice Address - Street 1:475 ROHNERT PARK EXPY W
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-7965
Practice Address - Country:US
Practice Address - Phone:707-585-2420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68420183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist