Provider Demographics
NPI:1699846600
Name:MEDICAL TREE PHARMACY INC
Entity Type:Organization
Organization Name:MEDICAL TREE PHARMACY INC
Other - Org Name:TOMS MEDICAL PHARMACY WESTSIDE
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MCFALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:831-426-4252
Mailing Address - Street 1:1203 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060
Mailing Address - Country:US
Mailing Address - Phone:831-426-4252
Mailing Address - Fax:831-471-0504
Practice Address - Street 1:1203 MISSION ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060
Practice Address - Country:US
Practice Address - Phone:831-426-4252
Practice Address - Fax:831-471-0504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CAPHY3756303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0567000OtherOTHER ID NUMBER
CAPHA375630Medicaid
0567000OtherOTHER ID NUMBER