Healthcare Provider Details

I. General information

NPI: 1497069264
Provider Name (Legal Business Name): MARTHA S MAZUR-LANE PHARM D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 11/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 AIRPORT PARK BLVD
UKIAH CA
95482-7400
US

IV. Provider business mailing address

1900 SANTA ROSA AVE
SANTA ROSA CA
95407-7621
US

V. Phone/Fax

Practice location:
  • Phone: 707-313-8014
  • Fax: 707-313-8005
Mailing address:
  • Phone: 707-578-1711
  • Fax: 707-578-6287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number41875
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number41875
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: