Provider Demographics
NPI:1609943281
Name:STEPHEN G FISK
Entity Type:Organization
Organization Name:STEPHEN G FISK
Other - Org Name:TRINITY PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FISK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:530-623-3250
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96093-0460
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1131 MAIN ST
Practice Address - Street 2:STE 100
Practice Address - City:WEAVERVILLE
Practice Address - State:CA
Practice Address - Zip Code:96093-0460
Practice Address - Country:US
Practice Address - Phone:530-623-3250
Practice Address - Fax:530-623-9419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY451933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0560133OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA451930Medicaid
CAPHA451930Medicaid