MEDICARE: STUDENT HEALTH CTR PHARMACY

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	261QH0100X	Health Service Clinic/Center	PHE19589	CA
2	261QS1000X	Student Health Clinic/Center	PHE 19589	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PHE 19589	OTHER	CA	RETAIL PHARMACY LICENSE

General Provider Information

NPI Number	:	1699838763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STUDENT HEALTH CTR PHARMACY

Provider Business Mailing Address
First Line	:	1801 E. COTATI AVE
Second Line	:	STUDENT HEALTH CENTER
City	:	ROHNERT PARK
State	:	CA
Zip	:	94928
Country	:	US
Telephone Number	:	707-664-2921
Fax Number	:	707-664-2925

Provider Business Practice Location Address
First Line	:	1801 E COTATI AVE
Second Line	:	STUDENT HEALTH CENTER
City	:	ROHNERT PARK
State	:	CA
Zip	:	94928-3613
Country	:	US
Telephone Number	:	707-664-2921
Fax Number	:	707-664-2925

Authorized Official
Title or Position	:	PHARMACIST IN CHARGE
Name	:	MR. IRVIN WILLIAM WHITAKER
Credential	:	R.PH.
Telephone Number	:	707-664-2921

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	03/07/2023

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Directions to “STUDENT HEALTH CTR PHARMACY ” Practice Location

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