Provider Demographics
NPI:1467902288
Name:BALTAZAR, JOVEN
Entity Type:Individual
Prefix:
First Name:JOVEN
Middle Name:
Last Name:BALTAZAR
Suffix:
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 1:1183 PEMBROKE DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-2837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 EUREKA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3027
Practice Address - Country:US
Practice Address - Phone:408-757-2615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75038183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist