Provider Demographics
NPI:1588765986
Name:CHRISTINE QUESENBERRY INCORPORATED
Entity type:Organization
Organization Name:CHRISTINE QUESENBERRY INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUESENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-247-4809
Mailing Address - Street 1:1401 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4738
Mailing Address - Country:US
Mailing Address - Phone:831-423-7175
Mailing Address - Fax:831-423-9417
Practice Address - Street 1:1401 MISSION ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4738
Practice Address - Country:US
Practice Address - Phone:831-423-7175
Practice Address - Fax:831-423-9417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
CAPHY3785203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA378520Medicaid
CA1250780001Medicare NSC
CAPHA378520Medicare PIN
CA=========Medicare UPIN