Provider Demographics
NPI:1750506796
Name:CHURN CREEK PHARMACY, INC.
Entity type:Organization
Organization Name:CHURN CREEK PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:FRUZZA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:530-222-3038
Mailing Address - Street 1:3330 CHURN CREEK RD
Mailing Address - Street 2:SUITE A1
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-2532
Mailing Address - Country:US
Mailing Address - Phone:530-222-3038
Mailing Address - Fax:530-222-0337
Practice Address - Street 1:3330 CHURN CREEK RD
Practice Address - Street 2:SUITE A1
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-2532
Practice Address - Country:US
Practice Address - Phone:530-222-3038
Practice Address - Fax:530-222-0337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY3249203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA324920Medicaid