Provider Demographics
NPI:1518376979
Name:MAZZA, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MAZZA
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 1:11 BLOSSOM DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-5213
Mailing Address - Country:US
Mailing Address - Phone:808-426-0077
Mailing Address - Fax:
Practice Address - Street 1:4625 REDWOOD DR
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-7941
Practice Address - Country:US
Practice Address - Phone:707-586-3624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-10
Last Update Date:2014-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist