Provider Demographics
NPI:1306127261
Name:VIVAR, CHARISSE MAY C (PHARMD)
Entity type:Individual
Prefix:
First Name:CHARISSE MAY
Middle Name:C
Last Name:VIVAR
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:CHARISSE MAY
Other - Middle Name:V
Other - Last Name:CAROLINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:4385 WEATHERVANE WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-4207
Mailing Address - Country:US
Mailing Address - Phone:415-990-5951
Mailing Address - Fax:
Practice Address - Street 1:5342 DUDLEY BLVD
Practice Address - Street 2:VA NORTHERN CALIFORNIA HEALTH CARE SYSTEM 119/MCC
Practice Address - City:MCCLELLAN
Practice Address - State:CA
Practice Address - Zip Code:95652-1012
Practice Address - Country:US
Practice Address - Phone:916-561-7422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018777183500000X
CA66500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist