Provider Demographics
NPI:1760895007
Name:PRIEST, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PRIEST
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 1:15025 OLYMPIC DR
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-9526
Mailing Address - Country:US
Mailing Address - Phone:707-994-8677
Mailing Address - Fax:
Practice Address - Street 1:15025 OLYMPIC DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9526
Practice Address - Country:US
Practice Address - Phone:916-300-8259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67141183500000X
NMRP00007718183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist