Provider Demographics
NPI:1396726634
Name:RODERICK PHARMACY GROUP INC
Entity type:Organization
Organization Name:RODERICK PHARMACY GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:209-465-1001
Mailing Address - Street 1:PO BOX 1651
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-1651
Mailing Address - Country:US
Mailing Address - Phone:209-465-1001
Mailing Address - Fax:209-946-1001
Practice Address - Street 1:711 E MARKET ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-3104
Practice Address - Country:US
Practice Address - Phone:209-465-1001
Practice Address - Fax:209-946-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY438913336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1992342OtherPK
CAPHA438910Medicaid