Peter James Economen, PHARMD
Individual provider Active NPI Pharmacist · Fort Bragg, CA
NPI 1639646557 · NPPES record last updated Oct 29, 2018
Key facts
- NPI
- 1639646557
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pharmacist 183500000X
- License
- 79810 (CA)
- Practice address
- 150 S Main St
Fort Bragg, CA 95437-4205 - Phone
- (707) 961-0464
- NPI assigned
- Oct 29, 2018
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- Credentials
- Doctor of Pharmacy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 79810 | CA | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Longs Drug Stores California LLC | Past | Accepting new patients | |
| Longs Drug Store California LLC | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 79810 | CA | Yes |
Addresses
Primary practice location
150 S Main St
Fort Bragg, CA 95437-4205
Mailing address
150 S Main St
Fort Bragg, CA 95437-4205
Phone (707) 961-0464
Other practice location 1
150 S Main St
Fort Bragg, CA 95437-4205
Phone (707) 961-0464
Other providers in Fort Bragg, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 29, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.