Healthcare Provider Details

I. General information

NPI: 1912559162
Provider Name (Legal Business Name): SAN JOAQUIN DRUG INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35300 HWY 41 SUITE 101
COARSEGOLD CA
93614
US

IV. Provider business mailing address

PO BOX 1636
PLANADA CA
95365
US

V. Phone/Fax

Practice location:
  • Phone: 559-692-2479
  • Fax:
Mailing address:
  • Phone: 209-382-1291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. KATHERINE ELIZABETH BASS
Title or Position: PRESIDENT
Credential: PHD
Phone: 209-484-8184