Provider Demographics
NPI:1023799244
Name:CHAGOLLA, JOHNNY ANTHONY (CPHT)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:ANTHONY
Last Name:CHAGOLLA
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26973 NEWPORT RD
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584
Mailing Address - Country:US
Mailing Address - Phone:951-301-6356
Mailing Address - Fax:
Practice Address - Street 1:26973 NEWPORT RD
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584
Practice Address - Country:US
Practice Address - Phone:951-301-6356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62803183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician