Provider Demographics
NPI:1013296656
Name:RAHARDJA, JIE GIOK (PHARMD)
Entity Type:Individual
Prefix:
First Name:JIE GIOK
Middle Name:
Last Name:RAHARDJA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 VERDE CT
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-1545
Mailing Address - Country:US
Mailing Address - Phone:707-769-9361
Mailing Address - Fax:
Practice Address - Street 1:401 BICENTENNIAL WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:707-393-4652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-14
Last Update Date:2011-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62966183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist