1104191592 NPI number — PGBB LLC

Table of content: (NPI 1104191592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104191592 NPI number — PGBB LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PGBB LLC
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:
SPECIALTY CARE RX
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:
1104191592
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 E KATELLA AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92867-4805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-941-6177
Provider Business Mailing Address Fax Number:
714-941-6178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 E KATELLA AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92867-4805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-941-6177
Provider Business Practice Location Address Fax Number:
714-941-6178
Provider Enumeration Date:
03/19/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MONTANO
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
714-941-6177

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PHY59102 . This is a "BOARD OF PHARMACY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 5643184 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".