=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447912191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARSHALL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2021
-----------------------------------------------------
Last Update Date | 11/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3581 PALMER DR STE 601
-----------------------------------------------------
City | CAMERON PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95682-8238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-344-5423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 MARSHALL WAY
-----------------------------------------------------
City | PLACERVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95667-6533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-626-2789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MRS. LAURIE ELDRIDGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-626-2780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------