=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477590834
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POKEY BONES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 08/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 CALLOWAY DR STE 701
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93312-2513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-410-7979
-----------------------------------------------------
Fax | 661-410-7980
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 CALLOWAY DR STE 701
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93312-2513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-410-7979
-----------------------------------------------------
Fax | 661-410-7980
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LISA FAAST
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 661-410-7979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY47454
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------