MEDICARE: COUNTRY VILLAGE 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	PHY34166	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1997702	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659465912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY VILLAGE PHARMACY

Provider Business Mailing Address
First Line	:	10251 COUNTRY CLUB DR
Second Line	:	STE B
City	:	MIRA LOMA
State	:	CA
Zip	:	91752-1329
Country	:	US
Telephone Number	:	951-681-8889
Fax Number	:	951-681-2948

Provider Business Practice Location Address
First Line	:	10251 COUNTRY CLUB DR
Second Line	:	STE B
City	:	MIRA LOMA
State	:	CA
Zip	:	91752-1329
Country	:	US
Telephone Number	:	951-681-8889
Fax Number	:	951-681-2948

Authorized Official
Title or Position	:	OWNER
Name	:	MOHAMMAD ARSHAD
Credential	:	PHARMACIST
Telephone Number	:	951-681-8889

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	01/23/2018

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Directions to “COUNTRY VILLAGE PHARMACY ” Practice Location

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