1174618862 NPI number — SEVENTH-DAY ADVENTISTS LOMA LINDA UNIVERSITY MEDICAL CENTER, INC.

Table of content: (NPI 1174618862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174618862 NPI number — SEVENTH-DAY ADVENTISTS LOMA LINDA UNIVERSITY MEDICAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEVENTH-DAY ADVENTISTS LOMA LINDA UNIVERSITY MEDICAL CENTER, 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:
CAMPUS 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:
1174618862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11161 ANDERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOMA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92354-2824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-558-4566
Provider Business Mailing Address Fax Number:
909-558-4586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11161 ANDERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOMA LINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92354-2824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-558-4566
Provider Business Practice Location Address Fax Number:
909-558-4586
Provider Enumeration Date:
10/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PARK
Authorized Official First Name:
EUGENE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY SUPERVISOR
Authorized Official Telephone Number:
909-558-4566

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHY35986 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 05-64434 . This is a "NAPB" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: PHA359860 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".