Provider Demographics
NPI:1013921881
Name:NEELEY, INC
Entity Type:Organization
Organization Name:NEELEY, INC
Other - Org Name:NORTH LAKE MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY TECH/MAMAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-263-6192
Mailing Address - Street 1:5136 HILL RD E
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-6300
Mailing Address - Country:US
Mailing Address - Phone:707-263-6192
Mailing Address - Fax:707-263-7839
Practice Address - Street 1:5136 HILL RD E
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6300
Practice Address - Country:US
Practice Address - Phone:707-263-6192
Practice Address - Fax:707-263-7839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHA2124003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY57297Medicaid
CA0417230001Medicare ID - Type UnspecifiedPROVIDER #