Healthcare Provider Details

I. General information

NPI: 1881616472
Provider Name (Legal Business Name): RUTH A STEWART
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 MAIN ST
KELSEYVILLE CA
95451-7420
US

IV. Provider business mailing address

PO BOX 727
KELSEYVILLE CA
95451-0727
US

V. Phone/Fax

Practice location:
  • Phone: 707-279-1561
  • Fax: 707-279-1000
Mailing address:
  • Phone: 707-279-1561
  • Fax: 707-279-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY46140
License Number StateCA

VIII. Authorized Official

Name: RUTH STEWART
Title or Position: OWNER
Credential: PHARMD
Phone: 707-279-1561