1487065041 NPI number — MR. PREBEN EHLERS EBBESEN RPH, PHARM D

Table of content: MR. PREBEN EHLERS EBBESEN RPH, PHARM D (NPI 1487065041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487065041 NPI number — MR. PREBEN EHLERS EBBESEN RPH, PHARM D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EBBESEN
Provider First Name:
PREBEN
Provider Middle Name:
EHLERS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPH, 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:
1487065041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3550 NORTH G STREET
Provider Second Line Business Mailing Address:
RALEY'S PHARMACY #309
Provider Business Mailing Address City Name:
MERCED
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95340-0691
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-722-3853
Provider Business Mailing Address Fax Number:
209-722-1711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3550 NORTH G STREET
Provider Second Line Business Practice Location Address:
RALEY'S PHARMACY #309
Provider Business Practice Location Address City Name:
MERCED
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95340-0691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-722-3853
Provider Business Practice Location Address Fax Number:
209-722-1711
Provider Enumeration Date:
05/15/2014

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:  RPH36685 , 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: RPH36685 . This is a "REGISTERED PHARMACIST CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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