Provider Demographics
NPI:1588675094
Name:BRANSCOMB PHARMACY CORPORATION
Entity Type:Organization
Organization Name:BRANSCOMB PHARMACY CORPORATION
Other - Org Name:BRANSCOMB PHARMACY CORP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IBUKUN
Authorized Official - Middle Name:
Authorized Official - Last Name:BANDELE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:707-984-8370
Mailing Address - Street 1:PO BOX 16
Mailing Address - Street 2:
Mailing Address - City:LAYTONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95454-0016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 BRANSCOMB RD
Practice Address - Street 2:#1
Practice Address - City:LAYTONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95454-0016
Practice Address - Country:US
Practice Address - Phone:707-984-8370
Practice Address - Fax:707-984-8372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CAPHY475253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115016OtherPK
CAPHA475250Medicaid