1275161325 NPI number — PHARMEDQUEST PHARMACY SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275161325 NPI number — PHARMEDQUEST PHARMACY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARMEDQUEST PHARMACY SERVICES
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:
AVITA PHARMACY 1016
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:
1275161325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10604 COURSEY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-4015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-599-8181
Provider Business Mailing Address Fax Number:
714-599-8242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8787 HALL RD RM A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93241-1953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-356-9536
Provider Business Practice Location Address Fax Number:
888-910-5286
Provider Enumeration Date:
04/01/2020

Additional Information

Authorized Official

Authorized Official Last Name:
IBARRA
Authorized Official First Name:
DALILA
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSING & CREDENTIALING COORDINAT
Authorized Official Telephone Number:
657-286-7957

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1275161325 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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