Provider Demographics
NPI:1982115176
Name:NAKATA, COREY MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:MICHAEL
Last Name:NAKATA
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 1:942 COBBLE SHORES DRIVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831
Mailing Address - Country:US
Mailing Address - Phone:916-215-4623
Mailing Address - Fax:
Practice Address - Street 1:420 W ACACIA ST STE 4
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2441
Practice Address - Country:US
Practice Address - Phone:209-466-2954
Practice Address - Fax:209-466-1558
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77592183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist