Provider Demographics
NPI:1922315852
Name:PAVELKO, TAISA V (PHARM D)
Entity Type:Individual
Prefix:
First Name:TAISA
Middle Name:V
Last Name:PAVELKO
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4980 FREEPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-2153
Mailing Address - Country:US
Mailing Address - Phone:916-247-4016
Mailing Address - Fax:
Practice Address - Street 1:4980 FREEPORT BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95822-2153
Practice Address - Country:US
Practice Address - Phone:916-247-4016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist