Provider Demographics
NPI:1578972931
Name:DYBA, RICHARD M
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:DYBA
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 1:166 PLACERVILLE DR
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-3919
Mailing Address - Country:US
Mailing Address - Phone:530-622-6630
Mailing Address - Fax:
Practice Address - Street 1:166 PLACERVILLE DR
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-3919
Practice Address - Country:US
Practice Address - Phone:530-622-6630
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
CA29725183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist