Provider Demographics
NPI:1235152984
Name:GERALD REICHELDERFER
Entity Type:Organization
Organization Name:GERALD REICHELDERFER
Other - Org Name:HAYFORK DRUGSTORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:REICHELDERFER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:530-628-5231
Mailing Address - Street 1:77 MAIN ST
Mailing Address - Street 2:PO BOX 370
Mailing Address - City:HAYFORK
Mailing Address - State:CA
Mailing Address - Zip Code:96041-0370
Mailing Address - Country:US
Mailing Address - Phone:530-628-5231
Mailing Address - Fax:530-628-1199
Practice Address - Street 1:77 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAYFORK
Practice Address - State:CA
Practice Address - Zip Code:96041-0370
Practice Address - Country:US
Practice Address - Phone:530-628-5231
Practice Address - Fax:530-628-1199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHA36152183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA361520Medicaid