Provider Demographics
NPI:1376577023
Name:NEELEY FAMILY, INC
Entity Type:Organization
Organization Name:NEELEY FAMILY, INC
Other - Org Name:NORTH LAKE MEDICAL PHARMACY #2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:NEELEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-263-1326
Mailing Address - Street 1:347 LAKEPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5412
Mailing Address - Country:US
Mailing Address - Phone:707-263-1328
Mailing Address - Fax:707-263-0864
Practice Address - Street 1:347 LAKEPORT BLVD
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5412
Practice Address - Country:US
Practice Address - Phone:707-263-1328
Practice Address - Fax:707-263-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY4127103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA412710Medicaid
CAPHA412710Medicaid