Provider Demographics
NPI:1891227864
Name:DIESH, VIJAY
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:
Last Name:DIESH
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 1:18 CRAMDEN DR
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-4144
Mailing Address - Country:US
Mailing Address - Phone:831-521-3742
Mailing Address - Fax:
Practice Address - Street 1:300 CANAL ST
Practice Address - Street 2:
Practice Address - City:KING CITY
Practice Address - State:CA
Practice Address - Zip Code:93930-3431
Practice Address - Country:US
Practice Address - Phone:831-385-7208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36333183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist