1245564848 NPI number — MR. KIRK ANTHONY SERUMGARD PHARM. D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245564848 NPI number — MR. KIRK ANTHONY SERUMGARD PHARM. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SERUMGARD
Provider First Name:
KIRK
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM. D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245564848
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2475A WEST 12TH STREET BLDG 780-A
Provider Second Line Business Mailing Address:
B/CO. 352 CSH USAR
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94607-5780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-302-2733
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
B/CO. 352 CSH USAR
Provider Second Line Business Practice Location Address:
2475A WEST 12TH STREET BLDG 780-A
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AA
Provider Business Practice Location Address Postal Code:
94607-5780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-302-2733
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  59365 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 59365 . This is a "BOARD OF PHARMACY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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