Healthcare Provider Details

I. General information

NPI: 1699838763
Provider Name (Legal Business Name): STUDENT HEALTH CTR PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 E COTATI AVE STUDENT HEALTH CENTER
ROHNERT PARK CA
94928-3613
US

IV. Provider business mailing address

1801 E. COTATI AVE STUDENT HEALTH CENTER
ROHNERT PARK CA
94928
US

V. Phone/Fax

Practice location:
  • Phone: 707-664-2921
  • Fax: 707-664-2925
Mailing address:
  • Phone: 707-664-2921
  • Fax: 707-664-2925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberPHE19589
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License NumberPHE 19589
License Number StateCA

VIII. Authorized Official

Name: MR. IRVIN WILLIAM WHITAKER
Title or Position: PHARMACIST IN CHARGE
Credential: R.PH.
Phone: 707-664-2921