Healthcare Provider Details

I. General information

NPI: 1689401630
Provider Name (Legal Business Name): CENTRAL COAST RX INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 09/16/2024
Certification Date: 09/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5735 EL CAMINO REAL STE H
ATASCADERO CA
93422-3350
US

IV. Provider business mailing address

5735 EL CAMINO REAL STE H
ATASCADERO CA
93422-3350
US

V. Phone/Fax

Practice location:
  • Phone: 805-460-9600
  • Fax: 805-460-9699
Mailing address:
  • Phone: 805-460-9600
  • Fax: 805-460-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. ABEL AGUILAR
Title or Position: CEO
Credential:
Phone: 805-460-9600