Healthcare Provider Details

I. General information

NPI: 1083759625
Provider Name (Legal Business Name): MOTHER LODE DRUG COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5034 COAKLEY CIRCLE DR.
MARIPOSA CA
95338-2099
US

IV. Provider business mailing address

PO BOX 2099
MARIPOSA CA
95338-2099
US

V. Phone/Fax

Practice location:
  • Phone: 209-742-7600
  • Fax: 209-742-7500
Mailing address:
  • Phone: 209-742-7600
  • Fax: 209-742-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY31052
License Number StateCA

VIII. Authorized Official

Name: MR. RICHARD A. RADANOVICH
Title or Position: PHARMACIST
Credential: RPH
Phone: 209-742-7600