Provider Demographics
NPI:1043246747
Name:SUTTER CENTRAL VALLEY HOSPITALS
Entity Type:Organization
Organization Name:SUTTER CENTRAL VALLEY HOSPITALS
Other - Org Name:MEMORIAL MEDICAL CENTER OUTPATIENT PHARM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BRESHEARS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:209-569-7352
Mailing Address - Street 1:1800 COFFEE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2705
Mailing Address - Country:US
Mailing Address - Phone:209-572-7132
Mailing Address - Fax:209-572-7077
Practice Address - Street 1:1800 COFFEE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2705
Practice Address - Country:US
Practice Address - Phone:209-572-7132
Practice Address - Fax:209-572-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHSP375963336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0538009OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHB375960Medicaid