=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609943281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEPHEN G FISK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 10/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1131 MAIN ST STE 100
-----------------------------------------------------
City | WEAVERVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96093-0460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-623-3250
-----------------------------------------------------
Fax | 530-623-9419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 460
-----------------------------------------------------
City | WEAVERVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96093-0460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEPHEN FISK
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 530-623-3250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY45193
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------