Provider Demographics
NPI:1255322863
Name:PALCO PHARMACY A CORP
Entity Type:Organization
Organization Name:PALCO PHARMACY A CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MERILYN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:707-764-3591
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:CA
Mailing Address - Zip Code:95565-0157
Mailing Address - Country:US
Mailing Address - Phone:707-764-3591
Mailing Address - Fax:707-764-3797
Practice Address - Street 1:113 MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:SCOTIA
Practice Address - State:CA
Practice Address - Zip Code:95565
Practice Address - Country:US
Practice Address - Phone:707-764-3591
Practice Address - Fax:707-764-3797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY43140333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA348600Medicaid
CA0533580002Medicare NSC
CAPHA348600Medicaid
CAZZZ15752ZMedicare PIN