Provider Demographics
NPI:1992074637
Name:PROVAN, STEVE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:STEVE
Middle Name:
Last Name:PROVAN
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 1:189 RIVER RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-1857
Mailing Address - Country:US
Mailing Address - Phone:916-501-9419
Mailing Address - Fax:
Practice Address - Street 1:430 BLUE RAVINE RD
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3402
Practice Address - Country:US
Practice Address - Phone:916-850-1195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46739183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist