Basic Information
| Provider Information | |||||||||
| NPI: | 1922308642 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORRECTIONS AND REHABILITATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NEUMILLER INFIRMARY PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | SAN QUENTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154541460 | ||||||||
| FaxNumber: | 4154194234 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | SAN QUENTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154541460 | ||||||||
| FaxNumber: | 4154194234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2010 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THARRATT | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | STATEWIDE CHIEF MEDICAL EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 9166919913 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CORRECTIONS AND REHABILITATION | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | 17378 | CA | N | Suppliers | Pharmacy | Institutional Pharmacy | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 5639212 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |