1639348964 NPI number — COLES CARE PHARMACY

Table of content: (NPI 1639348964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639348964 NPI number — COLES CARE PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLES CARE PHARMACY
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:
COLES CARE 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:
1639348964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16854 IVY AVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
FONTANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92335-1504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-356-0110
Provider Business Mailing Address Fax Number:
909-356-1024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16854 IVY AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
FONTANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92335-1504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-356-0110
Provider Business Practice Location Address Fax Number:
909-356-1024
Provider Enumeration Date:
02/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
COLE
Authorized Official First Name:
MISTY
Authorized Official Middle Name:
LAREE
Authorized Official Title or Position:
OWNER/PHARMACIST
Authorized Official Telephone Number:
909-356-0110

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY352970 , 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: 0596354 . This is a "NABP NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: PHA352970 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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