Provider Demographics
NPI:1982654992
Name:SUSANVILLE FAMILY PHARMACY INC
Entity Type:Organization
Organization Name:SUSANVILLE FAMILY PHARMACY INC
Other - Org Name:SUSANVILLE FAMILY PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:LIM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:530-242-6430
Mailing Address - Street 1:1850 SPRING RIDGE DR
Mailing Address - Street 2:STE P
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-6100
Mailing Address - Country:US
Mailing Address - Phone:530-257-8300
Mailing Address - Fax:530-257-9300
Practice Address - Street 1:1850 SPRING RIDGE DR
Practice Address - Street 2:STE P
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-6100
Practice Address - Country:US
Practice Address - Phone:530-257-8300
Practice Address - Fax:530-257-9300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY474763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5621950OtherNCPDP PROVIDER IDENTIFICATION NUMBER