1700393865 NPI number — MENDOCINO PHARMACY HOLDINGS INC.

Table of content: (NPI 1700393865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700393865 NPI number — MENDOCINO PHARMACY HOLDINGS INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENDOCINO PHARMACY HOLDINGS INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MENDOCINO VILLAGE PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700393865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 904
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENDOCINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95460-0904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-734-0091
Provider Business Mailing Address Fax Number:
707-962-3011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10501 LANSING ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENDOCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95460-0904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-937-4800
Provider Business Practice Location Address Fax Number:
707-937-5800
Provider Enumeration Date:
01/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BRODETSKY
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT,DIRECTOR,SOLE OWNER,PIC
Authorized Official Telephone Number:
707-734-0091

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PHA459890 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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