Provider Demographics
NPI:1457858565
Name:SEBASTOPOL FAMILY PHARMACY, INC.
Entity Type:Organization
Organization Name:SEBASTOPOL FAMILY PHARMACY, INC.
Other - Org Name:SEBASTOPOL FAMILY PHARMACY, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-869-9055
Mailing Address - Street 1:16251 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446-8300
Mailing Address - Country:US
Mailing Address - Phone:707-869-9055
Mailing Address - Fax:
Practice Address - Street 1:652 PETALUMA AVE STE I1
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4266
Practice Address - Country:US
Practice Address - Phone:707-869-9055
Practice Address - Fax:707-869-9861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY559593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176893OtherPK