Provider Demographics
NPI:1205392735
Name:MUNDY, DOUGLAS WILLIAM (RPH)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WILLIAM
Last Name:MUNDY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2074 LAKE TAHOE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6408
Mailing Address - Country:US
Mailing Address - Phone:530-541-0870
Mailing Address - Fax:530-541-0884
Practice Address - Street 1:2074 LAKE TAHOE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6408
Practice Address - Country:US
Practice Address - Phone:530-541-0870
Practice Address - Fax:530-541-0884
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHP33018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0548036Medicaid