Jeffrey Laist Gore, PHARMD
Individual provider Active NPI Pharmacist · Willits, CA
NPI 1891272142 · NPPES record last updated Jul 19, 2018
Key facts
- NPI
- 1891272142
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pharmacist 183500000X
- License
- 77724 (CA)
- Practice address
- 845 S Main St
Willits, CA 95490-3998 - Phone
- (707) 456-1790
- NPI assigned
- Jul 19, 2018
- Sex
- Male
- Sole proprietor
- No
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 |
|---|---|---|---|
| 77724 | CA | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Safeway Inc | Past | Accepting new patients | |
| Safeway Inc | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 77724 | CA | Yes |
Addresses
Primary practice location
845 S Main St
Willits, CA 95490-3998
Mailing address
PO Box 1804
Willits, CA 95490-1804
Other providers in Willits, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 19, 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.