1487745212 NPI number — SANTA MARIA PHARMACY INC

Table of content: BRIAN SHELLEY MD (NPI 1629084223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487745212 NPI number — SANTA MARIA PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANTA MARIA 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:
SANTA MARIA COMMUNITY 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:
1487745212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11004 VALLEY MALL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL MONTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91731-2617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-443-3089
Provider Business Mailing Address Fax Number:
626-443-8729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11004 VALLEY MALL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL MONTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91731-2617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-443-3089
Provider Business Practice Location Address Fax Number:
626-443-8729
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SOLIMAN
Authorized Official First Name:
MARCOS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
626-443-3089

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHY 50309 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY 50309 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PHY 50309 . This is a "RETAIL PHARMACY PERMIT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1487745212/PHA445980 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0531269 . This is a "NCPDP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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