1184600496 NPI number — DENNIS MICHAEL MCCOMB RPH

Table of content: DENNIS MICHAEL MCCOMB RPH (NPI 1184600496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184600496 NPI number — DENNIS MICHAEL MCCOMB RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCOMB
Provider First Name:
DENNIS
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1184600496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19444 ROSEWOOD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBRIDGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95258-9032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-334-2174
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 LAKEWOOD MALL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LODI
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95242-2963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-368-2788
Provider Business Practice Location Address Fax Number:
209-368-4951
Provider Enumeration Date:
12/19/2005

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:  28791 , 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: 28791 . This is a "PHARMACY LICENCE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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