Basic Information
| Provider Information | |||||||||
| NPI: | 1023254141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LINDEN STREET MENTAL HEALTH CENTER PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 LINDEN ST | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895023730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756882001 | ||||||||
| FaxNumber: | 7756882004 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 GALLETTI WAY | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894315564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756882001 | ||||||||
| FaxNumber: | 7756882004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2008 | ||||||||
| LastUpdateDate: | 12/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | O'BRIEN | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7756882030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE OF NEVADA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | IB02449 | NV | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | IB02449 | 01 | NV | PHARMACY LICENSE | OTHER | FL1147873 | 01 | DEA | OTHER |