1164238788 NPI number — AMERICAN HERITAGE PHARMACY INC

Table of content: MRS. DONNA KAYE AUSTIN FNP (NPI 1871581082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164238788 NPI number — AMERICAN HERITAGE PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMERICAN HERITAGE 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:
Provider Other Organization Name Type Code:
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:
1164238788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 E STATE HIGHWAY
Provider Second Line Business Mailing Address:
88
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95642-2134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-697-2000
Provider Business Mailing Address Fax Number:
209-697-2222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 E STATE HIGHWAY
Provider Second Line Business Practice Location Address:
88
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95642-2134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-697-2000
Provider Business Practice Location Address Fax Number:
209-697-2222
Provider Enumeration Date:
12/09/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KHUDANYAN
Authorized Official First Name:
ADRINE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
209-697-2000

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PHY59097 . This is a "BOARD OF PHARMACY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".