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General NPI Number Information
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NPI Number | 1073818258
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Entity Type | Organization
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Legal Business Name | PAQINC
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Dates
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Enumeration Date | 01/19/2011
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Last Update Date | 05/13/2011
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Provider Practice Location Address
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Address Line | 1409 S AIRPORT WAY
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City | STOCKTON
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State | CA
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Zip | 95206-2319
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Country | US
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Telephone | 209-939-9790
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Fax |
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Provider Business Mailing Address
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Address Line | 1409 S AIRPORT WAY
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City | STOCKTON
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State | CA
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Zip | 95206-2319
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Country | US
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Telephone | 209-939-9790
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Fax |
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Authorized Official
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Title or Position | PHARMACIST/PIC
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Name | WADE L. FULLMER
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Credential | RPH.
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Telephone | 209-939-0376
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 30915
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 50420
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License Number State | CA
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