Provider Demographics
NPI:1235341603
Name:CROSBY, PATRICK KENAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:KENAN
Last Name:CROSBY
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:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:CA
Mailing Address - Zip Code:95321-0809
Mailing Address - Country:US
Mailing Address - Phone:209-962-5211
Mailing Address - Fax:209-962-0963
Practice Address - Street 1:18638 MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:CA
Practice Address - Zip Code:95321-9458
Practice Address - Country:US
Practice Address - Phone:209-962-5211
Practice Address - Fax:209-962-0963
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42856183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGM613AOtherPTAN FOR MASS IMMUNIZATION ROSTER BILLER