Basic Information
| Provider Information | |||||||||
| NPI: | 1396839221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVAR | ||||||||
| FirstName: | DOLLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 FRUITVALE AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946012418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105354000 | ||||||||
| FaxNumber: | 5105354128 | ||||||||
| Practice Location | |||||||||
| Address1: | 3451 E 12TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105353375 | ||||||||
| FaxNumber: | 5105354169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RPH48974 | CA | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ29799Z | 01 | CA | FFS MEDICARE B | OTHER | ZZZ79046Z | 01 | CA | FFS MEDICARE B | OTHER | 551975 | 01 | CA | FFS MEDICARE A | OTHER | 051822 | 01 | CA | FQHC MEDICARE A | OTHER | FHC11991F | 05 | CA | MEDICAID | FHC71021F | 05 | CA | MEDICAID |