Provider Demographics
NPI:1992027825
Name:PIVA, GINO J (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:GINO
Middle Name:J
Last Name:PIVA
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 1:500 S 11TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:208-232-2408
Practice Address - Street 1:500 S 11TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4880
Practice Address - Country:US
Practice Address - Phone:208-232-7862
Practice Address - Fax:208-232-2408
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0010704183500000X
IDP5829183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist