Provider Demographics
NPI:1902961329
Name:RAYMOND Y FAT
Entity Type:Organization
Organization Name:RAYMOND Y FAT
Other - Org Name:SACRAMENTO MED PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARM
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:FAT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:916-739-1513
Mailing Address - Street 1:5270 ELVAS AVE
Mailing Address - Street 2:STE D
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-2332
Mailing Address - Country:US
Mailing Address - Phone:916-739-1513
Mailing Address - Fax:916-739-6674
Practice Address - Street 1:5270 ELVAS AVE
Practice Address - Street 2:STE D
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-2332
Practice Address - Country:US
Practice Address - Phone:916-739-1513
Practice Address - Fax:916-739-6674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY349103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0591859OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA34910AMedicaid