Provider Demographics
NPI:1134297906
Name:TAHOE CITY PLAZA PHARMACY
Entity Type:Organization
Organization Name:TAHOE CITY PLAZA PHARMACY
Other - Org Name:TAHOE CITY COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:SABISTINA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:530-583-3888
Mailing Address - Street 1:PO BOX 7229
Mailing Address - Street 2:
Mailing Address - City:TAHOE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:96145-7229
Mailing Address - Country:US
Mailing Address - Phone:530-583-3888
Mailing Address - Fax:530-583-1301
Practice Address - Street 1:599 NORTH LAKE BLVD
Practice Address - Street 2:
Practice Address - City:TAHOE CITY
Practice Address - State:CA
Practice Address - Zip Code:96145-7229
Practice Address - Country:US
Practice Address - Phone:530-583-3888
Practice Address - Fax:530-583-1301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 433403336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY 43340OtherRETAIL PHARMACY PERMIT
CAPHY 43340OtherRETAIL PHARMACY PERMIT