1306939749 NPI number — BUNNAUN UCH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306939749 NPI number — BUNNAUN UCH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BUNNAUN UCH
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:
ANGKOR 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:
1306939749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4555 N PERSHING AVE
Provider Second Line Business Mailing Address:
STE 7
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95207-6740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-473-4706
Provider Business Mailing Address Fax Number:
209-473-7377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4555 N PERSHING AVE
Provider Second Line Business Practice Location Address:
STE 7
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95207-6740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-888-2099
Provider Business Practice Location Address Fax Number:
209-888-2105
Provider Enumeration Date:
09/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
UCH
Authorized Official First Name:
BUNNAUN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PIC
Authorized Official Telephone Number:
209-888-2099

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2151610 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: PHA532620 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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