Healthcare Provider Details

I. General information

NPI: 1255617858
Provider Name (Legal Business Name): STON EDGAR YACKAMOUIH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 M ST
CRESCENT CITY CA
95531-4129
US

IV. Provider business mailing address

475 M ST
CRESCENT CITY CA
95531-4129
US

V. Phone/Fax

Practice location:
  • Phone: 707-465-3663
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH23762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: