Provider Demographics
NPI:1427145309
Name:PROFESSIONAL VILLAGE PHARMACY, INC.
Entity type:Organization
Organization Name:PROFESSIONAL VILLAGE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CLARKE
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:IV
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:916-483-3455
Mailing Address - Street 1:1701 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2104
Mailing Address - Country:US
Mailing Address - Phone:916-483-3455
Mailing Address - Fax:916-483-6745
Practice Address - Street 1:1701 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2104
Practice Address - Country:US
Practice Address - Phone:916-483-3455
Practice Address - Fax:916-483-6745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY46997332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0573077OtherNABP
CAPHA469970Medicaid
4394840001OtherMEDICARE PTAN