Healthcare Provider Details

I. General information

NPI: 1316011794
Provider Name (Legal Business Name): LUCERNE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6244 E HIGHWAY 20
LUCERNE CA
95458-1316
US

IV. Provider business mailing address

PO BOX 1316
LUCERNE CA
95458-1316
US

V. Phone/Fax

Practice location:
  • Phone: 707-274-6643
  • Fax: 707-274-2469
Mailing address:
  • Phone: 707-274-6643
  • Fax: 707-274-2469

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 NumberPHY46594
License Number StateCA

VIII. Authorized Official

Name: GAYLAN SHEPHERD
Title or Position: CEO AND PIC
Credential: RPH
Phone: 707-274-6643