Provider Demographics
NPI:1558442681
Name:SCOTT VALLEY PHARMACY INC
Entity Type:Organization
Organization Name:SCOTT VALLEY PHARMACY INC
Other - Org Name:SCOTT VALLEY DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-941-4032
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:ETNA
Mailing Address - State:CA
Mailing Address - Zip Code:96027-0610
Mailing Address - Country:US
Mailing Address - Phone:530-467-5335
Mailing Address - Fax:530-467-5111
Practice Address - Street 1:511 MAIN STREET
Practice Address - Street 2:
Practice Address - City:ETNA
Practice Address - State:CA
Practice Address - Zip Code:96027-0610
Practice Address - Country:US
Practice Address - Phone:530-467-5335
Practice Address - Fax:530-467-5111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY504633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA369010Medicaid
0554306OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA369010Medicaid