Provider Demographics
NPI:1285033209
Name:ITA, RYAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ITA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2226
Mailing Address - Country:US
Mailing Address - Phone:707-645-2520
Mailing Address - Fax:
Practice Address - Street 1:1761 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2226
Practice Address - Country:US
Practice Address - Phone:707-645-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61506183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist