Provider Demographics
NPI:1548639370
Name:CHAVIS, NOAH
Entity type:Individual
Prefix:
First Name:NOAH
Middle Name:
Last Name:CHAVIS
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 1:520 GOLDEN RIDGE RD APT D209
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-9532
Mailing Address - Country:US
Mailing Address - Phone:406-951-3179
Mailing Address - Fax:
Practice Address - Street 1:740 W ALLUVIAL AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-5509
Practice Address - Country:US
Practice Address - Phone:800-797-3543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0019525183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist