=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700384138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK MICHAEL SCHALO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2018
-----------------------------------------------------
Last Update Date | 01/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1060 E CYPRESS AVE
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96002-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-221-5575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8446 CROWN WAY
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96001-9545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-515-8447
-----------------------------------------------------
Fax | 530-244-0961
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 24100
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------