Provider Demographics
NPI:1225100860
Name:SHERIAN L PRINCE
Entity Type:Organization
Organization Name:SHERIAN L PRINCE
Other - Org Name:DBA PACIFIC MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-769-9606
Mailing Address - Street 1:620 PETALUMA BLVD N STE A
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2870
Mailing Address - Country:US
Mailing Address - Phone:707-769-9606
Mailing Address - Fax:707-776-4659
Practice Address - Street 1:620 PETALUMA BLVD N STE A
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2870
Practice Address - Country:US
Practice Address - Phone:707-769-9606
Practice Address - Fax:707-776-4659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100669332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME03174FMedicaid
CADME03174FMedicaid