Provider Demographics
NPI:1598032278
Name:REDWOOD COMPOUNDING PHARMACY INC
Entity Type:Organization
Organization Name:REDWOOD COMPOUNDING PHARMACY INC
Other - Org Name:REDWOOD COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:MOUSSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAILEMARIAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:707-541-6186
Mailing Address - Street 1:600 MARTIN AVE
Mailing Address - Street 2:STE 125
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-7919
Mailing Address - Country:US
Mailing Address - Phone:707-541-6186
Mailing Address - Fax:707-541-6287
Practice Address - Street 1:600 MARTIN AVE
Practice Address - Street 2:STE 125
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-7919
Practice Address - Country:US
Practice Address - Phone:707-541-6186
Practice Address - Fax:707-541-6287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY50691333600000X, 3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY50691OtherCALIFORNIA STATE BOARD OF PHARMACY RETAIL PERMIT