=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548752421
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAMERIN CORDELL PASSEY PHARMD, MBA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2018
-----------------------------------------------------
Last Update Date | 07/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1074 IDAHO ST STE 150
-----------------------------------------------------
City | ELKO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89801-3907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-264-4747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 328 AUSSIE HILL WAY
-----------------------------------------------------
City | SPRING CREEK
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89815-5698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-530-0894
-----------------------------------------------------
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 | 4046
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | P8007
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 20315
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------