Provider Demographics
NPI:1912392218
Name:PROKOLAB, IVONA
Entity Type:Individual
Prefix:
First Name:IVONA
Middle Name:
Last Name:PROKOLAB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79420 PASEO DEL REY
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-7218
Mailing Address - Country:US
Mailing Address - Phone:760-534-0289
Mailing Address - Fax:
Practice Address - Street 1:49908 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-9720
Practice Address - Country:US
Practice Address - Phone:760-771-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA626641835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist