Provider Demographics
NPI:1326368036
Name:GO, RYAN THELVIN (PHARMD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:THELVIN
Last Name:GO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16675 SLATE DR
Mailing Address - Street 2:323
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-7401
Mailing Address - Country:US
Mailing Address - Phone:707-712-9801
Mailing Address - Fax:
Practice Address - Street 1:25906 NEWPORT RD
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-9130
Practice Address - Country:US
Practice Address - Phone:951-679-5199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist