Provider Demographics
NPI:1972024073
Name:HIVALE, PHILLIP (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:HIVALE
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 1:11227 SAN MATEO DR APT A
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3274
Mailing Address - Country:US
Mailing Address - Phone:817-797-1254
Mailing Address - Fax:
Practice Address - Street 1:11227 SAN MATEO DR APT A
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3274
Practice Address - Country:US
Practice Address - Phone:817-797-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA686181835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care