Healthcare Provider Details

I. General information

NPI: 1609980671
Provider Name (Legal Business Name): MEDICAL DENTAL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 E NEES AVE
FRESNO CA
93720-2106
US

IV. Provider business mailing address

689 E NEES AVE
FRESNO CA
93720-2106
US

V. Phone/Fax

Practice location:
  • Phone: 559-439-1190
  • Fax: 559-439-1165
Mailing address:
  • Phone: 559-439-1190
  • Fax: 559-439-1165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY44342
License Number StateCA

VIII. Authorized Official

Name: DIANA SMITH
Title or Position: CEO
Credential: PHARMD
Phone: 559-439-1190