Provider Demographics
NPI:1356969711
Name:DAZA, PETER ADRIAN ALBA (PHARMACIST)
Entity type:Individual
Prefix:
First Name:PETER ADRIAN
Middle Name:ALBA
Last Name:DAZA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 BLUE RAVINE RD
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3402
Mailing Address - Country:US
Mailing Address - Phone:916-398-7617
Mailing Address - Fax:
Practice Address - Street 1:430 BLUE RAVINE RD
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3402
Practice Address - Country:US
Practice Address - Phone:916-398-7617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist