{
"Npi": {
"NPI": "1700393865",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "MENDOCINO PHARMACY HOLDINGS INC.",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 904",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MENDOCINO",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "95460-0904",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "707-734-0091",
"MailingAddressFaxNumber": "707-962-3011",
"FirstLinePracticeLocationAddress": "10501 LANSING ST.",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MENDOCINO",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "95460-0904",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "707-937-4800",
"PracticeLocationAddressFaxNumber": "707-937-5800",
"EnumerationDate": "01/10/2018",
"LastUpdateDate": "07/23/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BRODETSKY",
"AuthorizedOfficialFirstName": "KELLY",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PRESIDENT,DIRECTOR,SOLE OWNER,PIC",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PHARMD",
"AuthorizedOfficialTelephoneNumber": "707-734-0091",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}