Provider Demographics
NPI:1912155094
Name:SIERRA COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:SIERRA COMPOUNDING PHARMACY
Other - Org Name:SIERRA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:VASENDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-853-3500
Mailing Address - Street 1:9738 S VIRGINIA ST STE G
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-4811
Mailing Address - Country:US
Mailing Address - Phone:775-853-3500
Mailing Address - Fax:775-853-3501
Practice Address - Street 1:9738 S VIRGINIA ST STE G
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-4811
Practice Address - Country:US
Practice Address - Phone:775-853-3500
Practice Address - Fax:775-853-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPHC023773336C0003X
3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117749OtherPK
NV1912155094Medicaid