Provider Demographics
NPI:1437499936
Name:BROCK, DOUGLAS B (RPH)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:B
Last Name:BROCK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12110 INDUSTRY BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642
Mailing Address - Country:US
Mailing Address - Phone:209-257-0786
Mailing Address - Fax:209-257-0790
Practice Address - Street 1:12110 INDUSTRY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642
Practice Address - Country:US
Practice Address - Phone:209-257-0786
Practice Address - Fax:209-257-0790
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH33236183500000X
ORRPH0006930183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist