Provider Demographics
NPI:1255749685
Name:BAGSHAW, DARLENE
Entity type:Individual
Prefix:MRS
First Name:DARLENE
Middle Name:
Last Name:BAGSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-5748
Mailing Address - Country:US
Mailing Address - Phone:209-824-2121
Mailing Address - Fax:290-284-2728
Practice Address - Street 1:1205 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-5748
Practice Address - Country:US
Practice Address - Phone:209-824-2121
Practice Address - Fax:290-284-2728
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 42112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist