Provider Demographics
NPI:1649516428
Name:KETCHUM, DANIEL JOSEPH (RPH)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOSEPH
Last Name:KETCHUM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2072 DEVONPORT LOOP
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-8829
Mailing Address - Country:US
Mailing Address - Phone:916-945-7201
Mailing Address - Fax:
Practice Address - Street 1:6501 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0306
Practice Address - Country:US
Practice Address - Phone:916-537-5420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-22
Last Update Date:2012-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33070183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist