Provider Demographics
NPI:1558803510
Name:MY MEDICATION JOURNAL
Entity Type:Organization
Organization Name:MY MEDICATION JOURNAL
Other - Org Name:MY MEDICATION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:530-801-1702
Mailing Address - Street 1:PO BOX 2323
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-2323
Mailing Address - Country:US
Mailing Address - Phone:530-801-1702
Mailing Address - Fax:
Practice Address - Street 1:1272 EARLHAM LN
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-3268
Practice Address - Country:US
Practice Address - Phone:530-801-1702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization