Provider Demographics
NPI:1376556001
Name:SISKIYOU PHARMACY SERVICES INC
Entity Type:Organization
Organization Name:SISKIYOU PHARMACY SERVICES INC
Other - Org Name:MEDICAL CENTER PHARMACY / M C MEDICAL EQUIPMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:K
Authorized Official - Last Name:AMENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-842-4302
Mailing Address - Street 1:P.O. BOX 533
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-3319
Mailing Address - Country:US
Mailing Address - Phone:530-842-4302
Mailing Address - Fax:530-842-3796
Practice Address - Street 1:742 SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097
Practice Address - Country:US
Practice Address - Phone:530-842-4301
Practice Address - Fax:530-842-9416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44071183500000X
CA35335183500000X
CATCH65225183700000X
CATCH48386183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA466320Medicaid
0501189OtherNABP
CA5993600001Medicare NSC