Provider Demographics
NPI:1285076117
Name:RYLL, CHARLES WILLIAM
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:RYLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 AZALEA LANE
Mailing Address - Street 2:
Mailing Address - City:BERRY CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 AZALEA LANE
Practice Address - Street 2:
Practice Address - City:BERRY CREEK
Practice Address - State:CA
Practice Address - Zip Code:95916
Practice Address - Country:US
Practice Address - Phone:530-370-1339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32993183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist