Provider Demographics
NPI:1891231783
Name:RIVAC, JASON (RPH)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:RIVAC
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9886 REAGAN RD APT 232
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-3144
Mailing Address - Country:US
Mailing Address - Phone:916-425-0782
Mailing Address - Fax:
Practice Address - Street 1:9886 REAGAN RD APT 232
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-3144
Practice Address - Country:US
Practice Address - Phone:916-425-0782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74505183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist