Provider Demographics
NPI:1184994055
Name:VIVAR, DAYNE
Entity type:Individual
Prefix:
First Name:DAYNE
Middle Name:
Last Name:VIVAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 TOWN CENTER PLZ
Mailing Address - Street 2:T2268
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-4957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2005 TOWN CENTER PLZ
Practice Address - Street 2:T2268
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-4957
Practice Address - Country:US
Practice Address - Phone:916-384-0978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66189183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist