=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073653242
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOB'S GREENLEY PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 DELNERO DR
-----------------------------------------------------
City | SONORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95370-5221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 220-953-2313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 DELNERO DR
-----------------------------------------------------
City | SONORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95370-5221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOHN ROBERT WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 209-532-3139
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 45274
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------