Provider Demographics
NPI:1932407491
Name:IWATANI, WILLETTE
Entity Type:Individual
Prefix:
First Name:WILLETTE
Middle Name:
Last Name:IWATANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43621 PACIFIC COMMONS BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-3809
Mailing Address - Country:US
Mailing Address - Phone:510-897-1119
Mailing Address - Fax:
Practice Address - Street 1:43621 PACIFIC COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-3809
Practice Address - Country:US
Practice Address - Phone:510-897-1119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH412871835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist