Provider Demographics
NPI:1841767845
Name:DECOTA, ETHAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:DECOTA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1105 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1222
Practice Address - Country:US
Practice Address - Phone:707-443-5081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-28
Last Update Date:2018-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051299675183500000X
CA76432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist