Provider Demographics
NPI:1699436857
Name:VENTRESCA, VINCENT ANTHONY
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:ANTHONY
Last Name:VENTRESCA
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 1:80 SOUTH GIBSON ROAD APARTMENT #926
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012
Mailing Address - Country:US
Mailing Address - Phone:702-822-0161
Mailing Address - Fax:
Practice Address - Street 1:3490 STOCKTON HILL ROAD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409
Practice Address - Country:US
Practice Address - Phone:928-757-3338
Practice Address - Fax:928-757-8472
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS025647183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist