Provider Demographics
NPI:1912086695
Name:PACIFIC COMPOUNDING PHARMACY AND CONSULTATIONS, INC.
Entity Type:Organization
Organization Name:PACIFIC COMPOUNDING PHARMACY AND CONSULTATIONS, INC.
Other - Org Name:PACIFIC COMPUNDING PHARMACY AND CONSULTATIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:209-474-7271
Mailing Address - Street 1:312 LINCOLN CTR
Mailing Address - Street 2:NO SUITE NUMBER
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-2627
Mailing Address - Country:US
Mailing Address - Phone:209-474-7271
Mailing Address - Fax:209-474-7168
Practice Address - Street 1:312 LINCOLN CTR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-2627
Practice Address - Country:US
Practice Address - Phone:209-474-7271
Practice Address - Fax:209-474-7168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CAPHY474933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115225OtherPK