Healthcare Provider Details

I. General information

NPI: 1578604435
Provider Name (Legal Business Name): PALO CEDRO PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9180 DESCHUTES RD
PALO CEDRO CA
96073-8716
US

IV. Provider business mailing address

9180 DESCHUTES RD
PALO CEDRO CA
96073-8716
US

V. Phone/Fax

Practice location:
  • Phone: 530-547-4465
  • Fax: 530-547-4560
Mailing address:
  • Phone: 530-547-4465
  • Fax: 530-547-4560

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 NumberPHY47063
License Number StateCA

VIII. Authorized Official

Name: DEAN WOFFORD
Title or Position: OWNER
Credential: PHARM D
Phone: 530-547-4465