Organization
PAQINC
Active
Other names
Rancho San Miguel Pharmacy #21
Organization subpart
No
Provider details
NPI number
Authorized official
WADE L. FULLMER RPH. (PHARMACIST/PIC)
(209) 939-0376
Entity
Organization
Contact information
Practice address
1409 S AIRPORT WAY, STOCKTON, CA 95206-2319
(209) 939-9790
Mailing address
1409 S AIRPORT WAY, STOCKTON, CA 95206-2319
(209) 939-9790
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
30915
CA
3336C0003X
Community/Retail Pharmacy
Primary
50420
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
50420
PHARMACY BOARD LICENSE
CA
Enumeration date
01/19/2011
Last updated
05/13/2011
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