Provider Demographics
NPI:1104062801
Name:BESIO, FRED PAUL (RPH)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:PAUL
Last Name:BESIO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 S CLOVERDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-4010
Mailing Address - Country:US
Mailing Address - Phone:707-894-4414
Mailing Address - Fax:707-894-9379
Practice Address - Street 1:790 S CLOVERDALE BLVD
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:CA
Practice Address - Zip Code:95425-4010
Practice Address - Country:US
Practice Address - Phone:707-894-4414
Practice Address - Fax:707-894-9379
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-30
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 30988183500000X
CAPHY3653003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA365300Medicaid
CA6173610001Medicare NSC