Provider Demographics
NPI:1033263488
Name:PRESTON YOUTH CORRECTIONAL FACILITY
Entity Type:Organization
Organization Name:PRESTON YOUTH CORRECTIONAL FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHRM
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ERLEBUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:209-274-8275
Mailing Address - Street 1:201 WATERMAN RD
Mailing Address - Street 2:
Mailing Address - City:IONE
Mailing Address - State:CA
Mailing Address - Zip Code:95640-9701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 WATERMAN RD
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:CA
Practice Address - Zip Code:95640-9701
Practice Address - Country:US
Practice Address - Phone:209-274-8275
Practice Address - Fax:209-274-0865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCF446063336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5625174OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5625174OtherOTHER ID NUMBER