Provider Demographics
NPI:1225531858
Name:WILLIAMS, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4675 WATT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HIGHLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:95660-5517
Mailing Address - Country:US
Mailing Address - Phone:916-621-1455
Mailing Address - Fax:916-621-1456
Practice Address - Street 1:4675 WATT AVE
Practice Address - Street 2:
Practice Address - City:NORTH HIGHLANDS
Practice Address - State:CA
Practice Address - Zip Code:95660-5517
Practice Address - Country:US
Practice Address - Phone:916-621-1455
Practice Address - Fax:916-621-1456
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71236183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist