Provider Demographics
NPI:1407382781
Name:DEETON, ERICK SR
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:
Last Name:DEETON
Suffix:SR
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 1:10010 SEATTLE SLEW LN
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-5037
Mailing Address - Country:US
Mailing Address - Phone:916-627-5689
Mailing Address - Fax:
Practice Address - Street 1:8400 BRADSHAW RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1420
Practice Address - Country:US
Practice Address - Phone:916-689-1124
Practice Address - Fax:916-689-1157
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63051183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist