Healthcare Provider Details

I. General information

NPI: 1376830653
Provider Name (Legal Business Name): PAUL WILLIAM WILLIS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 S. MAIN ST.
YREKA CA
96097
US

IV. Provider business mailing address

12117 OLD WESTSIDE RD
GRENADA CA
96038-9607
US

V. Phone/Fax

Practice location:
  • Phone: 530-842-5596
  • Fax: 530-842-2882
Mailing address:
  • Phone: 530-859-0415
  • Fax: 530-436-2454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH27113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: