Healthcare Provider Details

I. General information

NPI: 1417483389
Provider Name (Legal Business Name): PROGRESSIVE PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 17TH ST STE 101
MODESTO CA
95354-1248
US

IV. Provider business mailing address

700 17TH ST SUITE 101
MODESTO CA
95354-1247
US

V. Phone/Fax

Practice location:
  • Phone: 209-857-4778
  • Fax: 209-422-6196
Mailing address:
  • Phone: 209-857-4778
  • Fax: 209-422-6196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY55632
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. MARCUS H HOWARD
Title or Position: PHARMACY MANAGER
Credential: PHARM.D
Phone: 209-857-4778