MEDICARE: PETER JAMES ECONOMEN PHARMD

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	183500000X	Pharmacist	79810	CA

General Provider Information

NPI Number	:	1639646557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER JAMES ECONOMEN PHARMD

Provider Business Mailing Address
First Line	:	150 S MAIN ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-4205
Country	:	US
Telephone Number	:	707-961-0464
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 S MAIN ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-4205
Country	:	US
Telephone Number	:	707-961-0464
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/29/2018
Last Update Date	:	10/29/2018

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