Provider Demographics
NPI:1992089049
Name:SAN VICENTE, CAROL B (RPH)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:B
Last Name:SAN VICENTE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:SAN VICENTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:3501 STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3227
Mailing Address - Country:US
Mailing Address - Phone:928-757-1999
Mailing Address - Fax:928-757-4441
Practice Address - Street 1:3501 STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3227
Practice Address - Country:US
Practice Address - Phone:928-757-1999
Practice Address - Fax:928-757-4441
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS013932183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist