Healthcare Provider Details

I. General information

NPI: 1992621668
Provider Name (Legal Business Name): MODOC FAMILY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9340 DESCHUTES RD
PALO CEDRO CA
96073-9763
US

IV. Provider business mailing address

PO BOX B
ILWACO WA
98624-0167
US

V. Phone/Fax

Practice location:
  • Phone: 530-233-3113
  • Fax: 530-233-3140
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JEFFREY SHANE HARRELL
Title or Position: OWNER
Credential:
Phone: 360-859-8659