Provider Demographics
NPI:1255510376
Name:BIDWELL PHARMACY AND MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:BIDWELL PHARMACY AND MEDICAL SUPPLY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:OKWUDILI
Authorized Official - Middle Name:
Authorized Official - Last Name:AHILIGWO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:530-891-0388
Mailing Address - Street 1:1200 MANGROVE AVE
Mailing Address - Street 2:STE A
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3558
Mailing Address - Country:US
Mailing Address - Phone:530-891-0388
Mailing Address - Fax:530-891-0324
Practice Address - Street 1:1200 MANGROVE AVE
Practice Address - Street 2:STE A
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3558
Practice Address - Country:US
Practice Address - Phone:530-891-0388
Practice Address - Fax:530-891-0324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CA488043336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1255510376Medicaid
5628512OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CA1255510376Medicaid