=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003953241
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLD COAST MEDICAL SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 02/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1551 NURSERY RD
-----------------------------------------------------
City | MCKINLEYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95519-3982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-633-6183
-----------------------------------------------------
Fax | 707-633-6184
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1551 NURSERY RD
-----------------------------------------------------
City | MCKINLEYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95519-3982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-633-6183
-----------------------------------------------------
Fax | 707-633-6184
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LARRY WADSWORTH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-443-2907
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY42086
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------