Provider Demographics
NPI:1104111384
Name:ORALLO, ALVIN REYNOLD MORTERA
Entity type:Individual
Prefix:
First Name:ALVIN REYNOLD
Middle Name:MORTERA
Last Name:ORALLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4707 PACIFIC AVE
Mailing Address - Street 2:T-0313
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6301
Mailing Address - Country:US
Mailing Address - Phone:209-954-9178
Mailing Address - Fax:
Practice Address - Street 1:4707 PACIFIC AVE
Practice Address - Street 2:T-0313
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6301
Practice Address - Country:US
Practice Address - Phone:209-954-9178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist