Healthcare Provider Details

I. General information

NPI: 1881605418
Provider Name (Legal Business Name): COW CREEK ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9390 DESCHUTES RD
PALO CEDRO CA
96073-9763
US

IV. Provider business mailing address

9390 DESCHUTES RD
PALO CEDRO CA
96073-9763
US

V. Phone/Fax

Practice location:
  • Phone: 530-547-4403
  • Fax: 530-547-4845
Mailing address:
  • Phone: 530-547-4403
  • Fax: 530-547-4845

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 NumberPHY47167
License Number StateCA

VIII. Authorized Official

Name: MARILYN HARNDEN
Title or Position: VP/MGR TECHNICIAN
Credential:
Phone: 530-547-4403