Provider Demographics
NPI:1952471450
Name:NUGGET MARKET PHARMACY
Entity Type:Organization
Organization Name:NUGGET MARKET PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOOTEBOOM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:530-662-0961
Mailing Address - Street 1:157 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-3125
Mailing Address - Country:US
Mailing Address - Phone:530-662-0961
Mailing Address - Fax:530-668-5597
Practice Address - Street 1:157 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-3125
Practice Address - Country:US
Practice Address - Phone:530-662-0961
Practice Address - Fax:530-668-5597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 404651835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA404650Medicaid