1093795577 NPI number — SPRING PARK PHARMACY INC

Table of content: (NPI 1093795577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093795577 NPI number — SPRING PARK PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRING PARK PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CEDAR PARK PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093795577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6226 E SPRING ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90815-1423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-630-8806
Provider Business Mailing Address Fax Number:
760-630-2406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
161 THUNDER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92083-6016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-758-7650
Provider Business Practice Location Address Fax Number:
760-758-8228
Provider Enumeration Date:
01/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEVINS
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
PIC
Authorized Official Telephone Number:
760-758-7650

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2127529 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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