Provider Demographics
NPI:1003953241
Name:GOLD COAST MEDICAL SERVICES INC
Entity Type:Organization
Organization Name:GOLD COAST MEDICAL SERVICES INC
Other - Org Name:GOLD COAST MEDICAL SERVICES, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WADSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-443-2907
Mailing Address - Street 1:1551 NURSERY RD
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-3982
Mailing Address - Country:US
Mailing Address - Phone:707-633-6183
Mailing Address - Fax:707-633-6184
Practice Address - Street 1:1551 NURSERY RD
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-3982
Practice Address - Country:US
Practice Address - Phone:707-633-6183
Practice Address - Fax:707-633-6184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY420863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA420860Medicaid
0538629OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5585260001Medicare NSC