1871695130 NPI number — IMGRX SJ VALLEY, INC.

Table of content: (NPI 1871695130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871695130 NPI number — IMGRX SJ VALLEY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMGRX SJ VALLEY, 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:
UNITED HEALTH CENTERS PHARMACY MENDOTA
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:
1871695130
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ATTN: CHC RETAIL PHARMACY DEPT. 13651 DUBLIN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAFFORD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-749-4000
Provider Business Mailing Address Fax Number:
614-652-0326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 BARBOZA ST
Provider Second Line Business Practice Location Address:
BUILDING 3
Provider Business Practice Location Address City Name:
MENDOTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93640-1901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-655-5000
Provider Business Practice Location Address Fax Number:
559-655-9604
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT, MANAGED SERVICES
Authorized Official Telephone Number:
281-749-4764

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY 54517 , 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: PHA462340 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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