Healthcare Provider Details

I. General information

NPI: 1922308642
Provider Name (Legal Business Name): CORRECTIONS AND REHABILITATION-HEADQUARTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MAIN STREET
SAN QUENTIN CA
94964
US

IV. Provider business mailing address

1 MAIN STREET
SAN QUENTIN CA
94964
US

V. Phone/Fax

Practice location:
  • Phone: 415-454-1460
  • Fax: 415-419-4234
Mailing address:
  • Phone: 415-454-1460
  • Fax: 415-419-4234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number17378
License Number StateCA

VIII. Authorized Official

Name: PIERRE CAESARE SAUCIER JAMES
Title or Position: STAFF SERVICES MANAGER I
Credential:
Phone: 510-780-6997