Provider Demographics
NPI:1629158308
Name:THOMAS D REIDENBACH
Entity Type:Organization
Organization Name:THOMAS D REIDENBACH
Other - Org Name:MYERS APOTHECARY SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:REIDENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-468-8991
Mailing Address - Street 1:238 HOSPITAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4559
Mailing Address - Country:US
Mailing Address - Phone:707-468-8991
Mailing Address - Fax:707-468-5272
Practice Address - Street 1:238 HOSPITAL DR STE A
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4559
Practice Address - Country:US
Practice Address - Phone:707-468-8991
Practice Address - Fax:707-468-5272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY442640333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY442640Medicaid
CA1277160001Medicare NSC