Provider Demographics
NPI:1427596956
Name:SALVADOR, IVIE
Entity Type:Individual
Prefix:
First Name:IVIE
Middle Name:
Last Name:SALVADOR
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 1:34 RANDALL LN # B
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-4117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1793 MARLOW RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4474
Practice Address - Country:US
Practice Address - Phone:707-544-8875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-04
Last Update Date:2017-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist