=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982654992
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSANVILLE FAMILY PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 06/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1850 SPRING RIDGE DR STE P
-----------------------------------------------------
City | SUSANVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96130-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-257-8300
-----------------------------------------------------
Fax | 530-257-9300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1850 SPRING RIDGE DR STE P
-----------------------------------------------------
City | SUSANVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96130-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-257-8300
-----------------------------------------------------
Fax | 530-257-9300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RONALD LIM
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 530-242-6430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY47476
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------