Provider Demographics
NPI:1801807391
Name:MEDICAL SPECIALTY PHARMACY
Entity type:Organization
Organization Name:MEDICAL SPECIALTY PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, AO
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:OKAMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-685-5034
Mailing Address - Street 1:C/O NUTRISHARE
Mailing Address - Street 2:9854 KENT ST
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624
Mailing Address - Country:US
Mailing Address - Phone:616-685-5034
Mailing Address - Fax:916-685-5588
Practice Address - Street 1:18433 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4108
Practice Address - Country:US
Practice Address - Phone:818-993-7333
Practice Address - Fax:818-993-7191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY509453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136091OtherPK