Provider Demographics
NPI:1699838763
Name:STUDENT HEALTH CTR PHARMACY
Entity Type:Organization
Organization Name:STUDENT HEALTH CTR PHARMACY
Other - Org Name:SONOMA STATE UNIVERSITY
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:IRVIN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:707-664-2921
Mailing Address - Street 1:1801 E. COTATI AVE
Mailing Address - Street 2:STUDENT HEALTH CENTER
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928
Mailing Address - Country:US
Mailing Address - Phone:707-664-2921
Mailing Address - Fax:707-664-2925
Practice Address - Street 1:1801 E COTATI AVE
Practice Address - Street 2:STUDENT HEALTH CENTER
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-3613
Practice Address - Country:US
Practice Address - Phone:707-664-2921
Practice Address - Fax:707-664-2925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHE19589261QH0100X
CAPHE 19589261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHE 19589OtherRETAIL PHARMACY LICENSE
CAAS9704607OtherDEA REGISTRATION
CAPHE 19589OtherRETAIL PHARMACY LICENSE