1760728380 NPI number — PECHANGA INDIAN HEALTH CLINIC PHARMACY

Table of content: (NPI 1760728380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760728380 NPI number — PECHANGA INDIAN HEALTH CLINIC PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PECHANGA INDIAN HEALTH CLINIC 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:
PECHANGA INDIAN HEALTH CLINIC 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:
1760728380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12784 PECHANGA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMECULA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92592
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-676-6810
Provider Business Mailing Address Fax Number:
951-676-6421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47001 PALA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMECULA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92592-2925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-676-6810
Provider Business Practice Location Address Fax Number:
951-676-6421
Provider Enumeration Date:
12/31/2012

Additional Information

Authorized Official

Authorized Official Last Name:
THOMSEN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
909-864-1097

Provider Taxonomy Codes

  • Taxonomy code: 332800000X , with the licence number:  50823 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5646178 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com