Provider Demographics
NPI:1386755940
Name:FRED P BESIO CLOVERDALE PHARMACY
Entity type:Organization
Organization Name:FRED P BESIO CLOVERDALE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BESIO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:707-894-4414
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY3653003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA365300Medicaid
CA0505529OtherNABP NUMBER
CA6173610001Medicare NSC