Healthcare Provider Details

I. General information

NPI: 1134297906
Provider Name (Legal Business Name): TAHOE CITY PLAZA PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

599 NORTH LAKE BLVD
TAHOE CITY CA
96145-7229
US

IV. Provider business mailing address

PO BOX 7229
TAHOE CITY CA
96145-7229
US

V. Phone/Fax

Practice location:
  • Phone: 530-583-3888
  • Fax: 530-583-1301
Mailing address:
  • Phone: 530-583-3888
  • Fax: 530-583-1301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHY 43340
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierPHY 43340
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerRETAIL PHARMACY PERMIT

VIII. Authorized Official

Name: GARY P SABISTINA
Title or Position: PHARMACIST
Credential: RPH
Phone: 530-583-3888