MEDICARE: SCRIPT DEPOT LP

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
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy
4	333600000X	Pharmacy	54491	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2164032	OTHER		PK

General Provider Information

NPI Number	:	1922290097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCRIPT DEPOT LP

Provider Business Mailing Address
First Line	:	866 PLUMAS ST
Second Line	:	STE C
City	:	YUBA CITY
State	:	CA
Zip	:	95991-4022
Country	:	US
Telephone Number	:	530-751-1889
Fax Number	:	530-674-3698

Provider Business Practice Location Address
First Line	:	866 PLUMAS ST
Second Line	:	STE C
City	:	YUBA CITY
State	:	CA
Zip	:	95991-4022
Country	:	US
Telephone Number	:	530-751-1889
Fax Number	:	530-674-3698

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	KHALED SEDKI
Credential	:
Telephone Number	:	248-790-2786

Provider Enumeration Date	:	08/13/2007
Last Update Date	:	02/07/2017

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Directions to “SCRIPT DEPOT LP ” Practice Location

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