1619965357 NPI number — PREVOST HEALTHCARE ENTERPRISES INC

Table of content: (NPI 1619965357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619965357 NPI number — PREVOST HEALTHCARE ENTERPRISES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREVOST HEALTHCARE ENTERPRISES 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:
WATTS PROFESSIONAL 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:
1619965357
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16709 AMBERWOOD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CERRITOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90703-1190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-564-3218
Provider Business Mailing Address Fax Number:
323-564-4064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9909 COMPTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90002-2850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-564-3218
Provider Business Practice Location Address Fax Number:
323-564-4064
Provider Enumeration Date:
10/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PREVOST
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
JEROME
Authorized Official Title or Position:
PHARMACIST CEO
Authorized Official Telephone Number:
323-564-3218

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  PHA371080 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY37108 , 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: PHA371080 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com