Healthcare Provider Details

I. General information

NPI: 1457823155
Provider Name (Legal Business Name): SHEDRICK MARTIN PHARMD, BCPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SMITH RANCH RD
SAN RAFAEL CA
94903-1939
US

IV. Provider business mailing address

111 SMITH RANCH RD
SAN RAFAEL CA
94903-1939
US

V. Phone/Fax

Practice location:
  • Phone: 415-491-3000
  • Fax:
Mailing address:
  • Phone: 415-491-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number77539
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number77539
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number7539
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number77539
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number77539
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: