=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700393865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENDOCINO PHARMACY HOLDINGS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2018
-----------------------------------------------------
Last Update Date | 07/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10501 LANSING ST.
-----------------------------------------------------
City | MENDOCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95460-0904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-937-4800
-----------------------------------------------------
Fax | 707-937-5800
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 904
-----------------------------------------------------
City | MENDOCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95460-0904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-734-0091
-----------------------------------------------------
Fax | 707-962-3011
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT,DIRECTOR,SOLE OWNER,PIC
-----------------------------------------------------
Name | KELLY BRODETSKY
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 707-734-0091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------