1689656704 NPI number — SHIVSA

Table of content: (NPI 1689656704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689656704 NPI number — SHIVSA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHIVSA
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:
BOIES MEDICAL CENTER 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:
1689656704
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
828 DELBON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TURLOCK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95382
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-634-8511
Provider Business Mailing Address Fax Number:
209-634-3839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
828 DELBON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TURLOCK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-634-8511
Provider Business Practice Location Address Fax Number:
209-634-3839
Provider Enumeration Date:
11/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ANNE
Authorized Official First Name:
PRATAP
Authorized Official Middle Name:
K
Authorized Official Title or Position:
MANAGING MEMBER/PHARMACY DIRECTOR
Authorized Official Telephone Number:
209-298-1715

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY55568 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; 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: "N" .

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

  • Identifier: 2168554 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1689656704 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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