Healthcare Provider Details

I. General information

NPI: 1780129908
Provider Name (Legal Business Name): PHARMATEMP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/25/2016
Last Update Date: 12/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 CEDAR CREEK CT APT 159
MODESTO CA
95355-5250
US

IV. Provider business mailing address

1120 CEDAR CREEK CT APT 159
MODESTO CA
95355-5250
US

V. Phone/Fax

Practice location:
  • Phone: 209-447-8475
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number26560
License Number StateCA

VIII. Authorized Official

Name: MR. GORDON PHILLIP KOST
Title or Position: RPH
Credential:
Phone: 209-447-8475