Provider Demographics
NPI:1497124572
Name:SISE, DARIN (43429)
Entity Type:Individual
Prefix:
First Name:DARIN
Middle Name:
Last Name:SISE
Suffix:
Gender:M
Credentials:43429
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 FLOYD AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-9637
Mailing Address - Country:US
Mailing Address - Phone:209-550-6030
Mailing Address - Fax:
Practice Address - Street 1:3020 FLOYD AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-9637
Practice Address - Country:US
Practice Address - Phone:209-550-6030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist