Provider Demographics
NPI:1932511771
Name:HAZARD, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:HAZARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 LAKE TAHOE BLVD
Mailing Address - Street 2:#6
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-7071
Mailing Address - Country:US
Mailing Address - Phone:530-544-4111
Mailing Address - Fax:530-544-1797
Practice Address - Street 1:4000 LAKE TAHOE BLVD
Practice Address - Street 2:#6
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7071
Practice Address - Country:US
Practice Address - Phone:530-544-4111
Practice Address - Fax:530-544-1797
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY38240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY37849Medicaid