Healthcare Provider Details

I. General information

NPI: 1699848663
Provider Name (Legal Business Name): GUALALA PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39351 S HIGHWAY 1
GUALALA CA
95445-9571
US

IV. Provider business mailing address

PO BOX 528 39351 S. HWY 1
GUALALA CA
95445-0528
US

V. Phone/Fax

Practice location:
  • Phone: 707-884-4107
  • Fax: 707-884-9024
Mailing address:
  • Phone: 707-884-4107
  • Fax: 707-884-9024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY47064
License Number StateCA

VIII. Authorized Official

Name: MR. JOHN JAMES CHLADEK
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 707-884-4107