Provider Demographics
NPI:1487065041
Name:EBBESEN, PREBEN EHLERS (RPH, PHARM D)
Entity type:Individual
Prefix:MR
First Name:PREBEN
Middle Name:EHLERS
Last Name:EBBESEN
Suffix:
Gender:M
Credentials:RPH, PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 NORTH G STREET
Mailing Address - Street 2:RALEY'S PHARMACY #309
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-0691
Mailing Address - Country:US
Mailing Address - Phone:209-722-3853
Mailing Address - Fax:209-722-1711
Practice Address - Street 1:3550 NORTH G STREET
Practice Address - Street 2:RALEY'S PHARMACY #309
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-0691
Practice Address - Country:US
Practice Address - Phone:209-722-3853
Practice Address - Fax:209-722-1711
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH36685183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARPH36685OtherREGISTERED PHARMACIST CALIFORNIA