Provider Demographics
NPI:1396384350
Name:DEFOSSES, RICKY (RPH)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:DEFOSSES
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 S AVENIDA CABALLEROS UNIT 248
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-6767
Mailing Address - Country:US
Mailing Address - Phone:512-924-7249
Mailing Address - Fax:
Practice Address - Street 1:14200 PALM DR
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-6873
Practice Address - Country:US
Practice Address - Phone:760-329-1889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-22
Last Update Date:2019-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist