Provider Demographics
NPI:1568611531
Name:SMITH, DONALD W
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:W
Last Name:SMITH
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 1:937 N YOSEMITE ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-2216
Mailing Address - Country:US
Mailing Address - Phone:209-465-2671
Mailing Address - Fax:
Practice Address - Street 1:104 LINCOLN CTR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-2607
Practice Address - Country:US
Practice Address - Phone:209-956-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHP37871183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY49148OtherPHARMACY LICENSE