Provider Demographics
NPI:1669785275
Name:ONGSIOCO, JOHANNA ANTIVOLA (PHARMACIST)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:ANTIVOLA
Last Name:ONGSIOCO
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 LILLARD DR APT 120
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-4883
Mailing Address - Country:US
Mailing Address - Phone:707-315-9858
Mailing Address - Fax:530-231-5286
Practice Address - Street 1:295 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-3691
Practice Address - Country:US
Practice Address - Phone:530-662-1795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-24
Last Update Date:2010-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63657183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist