Provider Demographics
NPI:1073818258
Name:PAQINC
Entity Type:Organization
Organization Name:PAQINC
Other - Org Name:RANCHO SAN MIGUEL PHARMACY #21
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/PIC
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FULLMER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:209-939-0376
Mailing Address - Street 1:1409 S AIRPORT WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-2319
Mailing Address - Country:US
Mailing Address - Phone:209-939-9790
Mailing Address - Fax:
Practice Address - Street 1:1409 S AIRPORT WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-2319
Practice Address - Country:US
Practice Address - Phone:209-939-9790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30915183500000X
CA504203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA50420OtherPHARMACY BOARD LICENSE