Healthcare Provider Details

I. General information

NPI: 1013001429
Provider Name (Legal Business Name): SISKIN'S SAN CARLOS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 LAUREL ST
SAN CARLOS CA
94070-3914
US

IV. Provider business mailing address

825 LAUREL ST
SAN CARLOS CA
94070-3914
US

V. Phone/Fax

Practice location:
  • Phone: 650-591-9636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY32600
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ROBERT SISKIN
Title or Position: PRESIDENT
Credential:
Phone: 650-591-9636