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General NPI Number Information
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NPI Number | 1205453586
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Entity Type | Organization
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Legal Business Name | MENDOCINO PHARMACY HOLDINGS INC.
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Dates
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Enumeration Date | 07/02/2020
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Last Update Date | 07/02/2020
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Provider Practice Location Address
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Address Line | 39251 SOUTH HIGHWAY 1
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City | GUALALA
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State | CA
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Zip | 95445
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Country | US
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Telephone | 707-734-0091
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Fax | 707-962-3011
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Provider Business Mailing Address
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Address Line | PO BOX 904
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City | MENDOCINO
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State | CA
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Zip | 95460-0904
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Country | US
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Telephone | 707-734-0091
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Fax | 707-962-3011
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Authorized Official
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Title or Position | PRESIDENT, DIRECTOR
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Name | KELLY E BRODETSKY
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Credential | PHARMD
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Telephone | 707-734-0091
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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