Provider Demographics
NPI:1699848663
Name:GUALALA PHARMACY, INC.
Entity Type:Organization
Organization Name:GUALALA PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CHLADEK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:707-884-4107
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:39351 S. HWY 1
Mailing Address - City:GUALALA
Mailing Address - State:CA
Mailing Address - Zip Code:95445-0528
Mailing Address - Country:US
Mailing Address - Phone:707-884-4107
Mailing Address - Fax:707-884-9024
Practice Address - Street 1:39351 S HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:GUALALA
Practice Address - State:CA
Practice Address - Zip Code:95445-9571
Practice Address - Country:US
Practice Address - Phone:707-884-4107
Practice Address - Fax:707-884-9024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY470643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy