MEDICARE: BIG BEAR PHARMACY

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PHY39801	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0596796	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1629170022
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIG BEAR PHARMACY

Provider Business Mailing Address
First Line	:	PO BOX 1667
Second Line	:
City	:	BIG BEAR LAKE
State	:	CA
Zip	:	92315-1667
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	41965 BIG BEAR BLVD
Second Line	:
City	:	BIG BEAR LAKE
State	:	CA
Zip	:	92315-1667
Country	:	US
Telephone Number	:	909-886-2112
Fax Number	:	909-866-7142

Authorized Official
Title or Position	:	CEO
Name	:	RICHARD LAMBERT
Credential	:	PHARM D
Telephone Number	:	909-866-6612

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	08/31/2007

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Directions to “BIG BEAR PHARMACY ” Practice Location

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