1053452227 NPI number — FRIENDLY HILLS MEDICAL CENTER PHARMACY INC

Table of content: (NPI 1053452227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053452227 NPI number — FRIENDLY HILLS MEDICAL CENTER PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FRIENDLY HILLS MEDICAL CENTER 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:
6
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:
1053452227
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12675 LA MIRADA BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA MIRADA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90638-2249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-777-8175
Provider Business Mailing Address Fax Number:
562-777-7156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12675 LA MIRADA BLVD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA MIRADA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90638-2249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-777-8175
Provider Business Practice Location Address Fax Number:
562-777-7156
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALL
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST IN CHARGE
Authorized Official Telephone Number:
562-777-8175

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY44769 , 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: PHA447690 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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