Provider Demographics
NPI:1417933466
Name:BESEDA, MARK PAUL (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:PAUL
Last Name:BESEDA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 OLD RANCH CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4841
Mailing Address - Country:US
Mailing Address - Phone:209-477-7262
Mailing Address - Fax:
Practice Address - Street 1:3233 W HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-2751
Practice Address - Country:US
Practice Address - Phone:209-952-1212
Practice Address - Fax:209-952-1232
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33386183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist