Provider Demographics
NPI:1952483737
Name:RICHLAND PHARMACY
Entity Type:Organization
Organization Name:RICHLAND PHARMACY
Other - Org Name:RICHLAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC AND VP
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLMER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:209-667-5588
Mailing Address - Street 1:2090 E CANAL DR
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95380-4302
Mailing Address - Country:US
Mailing Address - Phone:209-667-5588
Mailing Address - Fax:209-667-4935
Practice Address - Street 1:2090 E CANAL DR
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95380-4302
Practice Address - Country:US
Practice Address - Phone:209-667-5588
Practice Address - Fax:209-667-4935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
CAPHY303133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0569547OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA303130Medicaid
4828770001Medicare NSC