Provider Demographics
NPI:1215002902
Name:VACCA, MARTIN KINSMAN (PHARM D)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:KINSMAN
Last Name:VACCA
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6013 SPRING VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301
Mailing Address - Country:US
Mailing Address - Phone:209-357-1884
Mailing Address - Fax:209-358-8639
Practice Address - Street 1:571 BELLEVUE RD
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301
Practice Address - Country:US
Practice Address - Phone:209-358-6306
Practice Address - Fax:209-358-8639
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 35524183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist