MEDICARE: PROFESSIONAL VILLAGE PHARMACY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	PHY46997	CA
2	3336C0003X	Community/Retail Pharmacy

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	4394840001	OTHER		MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0573077	OTHER	CA	NABP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427145309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL VILLAGE PHARMACY, INC.

Provider Business Mailing Address
First Line	:	1701 PROFESSIONAL DR
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95825-2104
Country	:	US
Telephone Number	:	916-483-3455
Fax Number	:	916-483-6745

Provider Business Practice Location Address
First Line	:	1701 PROFESSIONAL DR
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95825-2104
Country	:	US
Telephone Number	:	916-483-3455
Fax Number	:	916-483-6745

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN CLARKE RICHARDS IV
Credential	:	PHARM.D.
Telephone Number	:	916-483-3455

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	08/22/2014

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Directions to “PROFESSIONAL VILLAGE PHARMACY, INC. ” Practice Location

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