Healthcare Provider Details

I. General information

NPI: 1912086695
Provider Name (Legal Business Name): PACIFIC COMPOUNDING PHARMACY AND CONSULTATIONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 LINCOLN CTR
STOCKTON CA
95207-2627
US

IV. Provider business mailing address

312 LINCOLN CTR NO SUITE NUMBER
STOCKTON CA
95207-2627
US

V. Phone/Fax

Practice location:
  • Phone: 209-474-7271
  • Fax: 209-474-7168
Mailing address:
  • Phone: 209-474-7271
  • Fax: 209-474-7168

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 NumberPHY47493
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARIE COTTMAN
Title or Position: PRESIDENT
Credential: PHARM D
Phone: 209-474-7271