Provider Demographics
NPI:1841384336
Name:DOUGLAS W. MUNDY
Entity Type:Organization
Organization Name:DOUGLAS W. MUNDY
Other - Org Name:TAHOE VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:MUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:530-541-0870
Mailing Address - Street 1:2074 LAKE TAHOE BLVD.
Mailing Address - Street 2:STE. #1
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150
Mailing Address - Country:US
Mailing Address - Phone:530-541-0870
Mailing Address - Fax:530-541-0884
Practice Address - Street 1:2074 LAKE TAHOE BLVD.
Practice Address - Street 2:STE. #1
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:530-541-0870
Practice Address - Fax:530-541-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY223863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy