Healthcare Provider Details

I. General information

NPI: 1386755940
Provider Name (Legal Business Name): FRED P BESIO CLOVERDALE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/11/2012
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 TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY365300
License Number StateCA

VIII. Authorized Official

Name: MR. FRED PAUL BESIO
Title or Position: OWNER/PHARMACIST
Credential: RPH
Phone: 707-894-4414