=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336399351
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILIO BETHENCOURT PHARM.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2008
-----------------------------------------------------
Last Update Date | 07/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2246 WILD PLAINS CIR
-----------------------------------------------------
City | ROCKLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95765-5371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-799-2477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2246 WILD PLAINS CIR
-----------------------------------------------------
City | ROCKLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95765-5371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-799-2477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 052377-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 45964
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------