Provider Demographics
NPI:1336399351
Name:BETHENCOURT, EMILIO (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:EMILIO
Middle Name:
Last Name:BETHENCOURT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2246 WILD PLAINS CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-5371
Mailing Address - Country:US
Mailing Address - Phone:916-799-2477
Mailing Address - Fax:
Practice Address - Street 1:2246 WILD PLAINS CIR
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-5371
Practice Address - Country:US
Practice Address - Phone:916-799-2477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052377-1183500000X
CA459641835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01994903Medicaid