=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588923700
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARMPAK, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2012
-----------------------------------------------------
Last Update Date | 05/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1221 ANDERSEN DR STE B
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-5337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-455-9981
-----------------------------------------------------
Fax | 415-455-8445
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1221 ANDERSEN DR STE B
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-5337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-455-9981
-----------------------------------------------------
Fax | 415-455-8445
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MARK HORNE
-----------------------------------------------------
Credential | PHARMACIST
-----------------------------------------------------
Telephone | 415-455-9981
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336M0002X
-----------------------------------------------------
Taxonomy Name | Mail Order Pharmacy
-----------------------------------------------------
License Number | WLS2834
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------