Provider Demographics
NPI:1700393865
Name:MENDOCINO PHARMACY HOLDINGS INC.
Entity type:Organization
Organization Name:MENDOCINO PHARMACY HOLDINGS INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT,DIRECTOR,SOLE OWNER,PIC
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODETSKY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:707-734-0091
Mailing Address - Street 1:PO BOX 904
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460-0904
Mailing Address - Country:US
Mailing Address - Phone:707-734-0091
Mailing Address - Fax:707-962-3011
Practice Address - Street 1:10501 LANSING ST.
Practice Address - Street 2:
Practice Address - City:MENDOCINO
Practice Address - State:CA
Practice Address - Zip Code:95460-0904
Practice Address - Country:US
Practice Address - Phone:707-937-4800
Practice Address - Fax:707-937-5800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA459890Medicaid
CABM7839220OtherDEA