Basic Information
| Provider Information | |||||||||
| NPI: | 1679832331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIOVANNONI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 OLIVIA WAY | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952094528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099517485 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4001 HWY 104 | ||||||||
| Address2: | ---- MULE CREEK STATE PRISON | ||||||||
| City: | IONE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092744911 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2012 | ||||||||
| LastUpdateDate: | 05/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RPH 31107 | CA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.