Healthcare Provider Details

I. General information

NPI: 1104062801
Provider Name (Legal Business Name): FRED PAUL BESIO RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2008
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 S CLOVERDALE BLVD
CLOVERDALE CA
95425-4010
US

IV. Provider business mailing address

790 S CLOVERDALE BLVD
CLOVERDALE CA
95425-4010
US

V. Phone/Fax

Practice location:
  • Phone: 707-894-4414
  • Fax: 707-894-9379
Mailing address:
  • Phone: 707-894-4414
  • Fax: 707-894-9379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH 30988
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY365300
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: