Healthcare Provider Details

I. General information

NPI: 1134919988
Provider Name (Legal Business Name): MAIN FORK PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41841 SIERRA DR
THREE RIVERS CA
93271-9795
US

IV. Provider business mailing address

41841 SIERRA DR
THREE RIVERS CA
93271-9795
US

V. Phone/Fax

Practice location:
  • Phone: 559-566-6801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARTIN BURNHAM
Title or Position: CEO
Credential:
Phone: 559-566-6801