Provider Demographics
NPI:1376274290
Name:CHAVEZ, DESIRAE MARIE
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:MARIE
Last Name:CHAVEZ
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 1:2604 BANCROFT DR
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1135 AVOCADO AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-7702
Practice Address - Country:US
Practice Address - Phone:619-447-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATCH94932183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician