MEDICARE: RODERICK PHARMACY GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336L0003X	Long Term Care Pharmacy	PHY43891	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1992342	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396726634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RODERICK PHARMACY GROUP INC

Provider Business Mailing Address
First Line	:	PO BOX 1651
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95201-1651
Country	:	US
Telephone Number	:	209-465-1001
Fax Number	:	209-946-1001

Provider Business Practice Location Address
First Line	:	711 E MARKET ST
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95202-3104
Country	:	US
Telephone Number	:	209-465-1001
Fax Number	:	209-946-1001

Authorized Official
Title or Position	:	CEO
Name	:	DAVID RODERICK
Credential	:	PHARMD
Telephone Number	:	209-465-1001

Provider Enumeration Date	:	11/11/2005
Last Update Date	:	09/13/2013

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