1669018727 NPI number — EL MIRADOR MEDICAL PLAZA PHARMACY INC

Table of content: MRS. DIANE DENIS MCCARTER JOHNSON LPN (NPI 1972778595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669018727 NPI number — EL MIRADOR MEDICAL PLAZA PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EL MIRADOR MEDICAL PLAZA 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:
1669018727
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1180 N INDIAN CANYON DR STE E140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM SPRINGS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92262-4883
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-323-1001
Provider Business Mailing Address Fax Number:
760-323-1144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1180 N INDIAN CANYON DR STE E140
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM SPRINGS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92262-4883
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-323-1001
Provider Business Practice Location Address Fax Number:
760-323-1144
Provider Enumeration Date:
11/25/2019

Additional Information

Authorized Official

Authorized Official Last Name:
UPADHYAYULA
Authorized Official First Name:
RAMESH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
760-323-1001

Provider Taxonomy Codes

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

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





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