Provider Demographics
NPI:1740024603
Name:DESANTIS, IVAN MICHAEL (RPH)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:MICHAEL
Last Name:DESANTIS
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 1:4455 CONNECTICUT AVE NW APT 605
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-2338
Mailing Address - Country:US
Mailing Address - Phone:323-529-4047
Mailing Address - Fax:
Practice Address - Street 1:2231 DOUGLAS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4264
Practice Address - Country:US
Practice Address - Phone:916-244-2085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist