1821356361 NPI number — DR. ELDA JUNE ROSCOE-GUSTAFSON PHARMACIST

Table of content: SHELBY KASCH BS, LAT (NPI 1710452156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821356361 NPI number — DR. ELDA JUNE ROSCOE-GUSTAFSON PHARMACIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSCOE-GUSTAFSON
Provider First Name:
ELDA
Provider Middle Name:
JUNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMACIST
Provider Gender Code:
F

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:
1821356361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3662 DOVE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERCED
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95340-9378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-201-9321
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 COMMERCE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATWATER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95301-5213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-357-4821
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2012

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:  RPH 38350 , 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)





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