1053490797 NPI number — SD HEALTHCARE RX NC

Table of content: (NPI 1053490797)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053490797 NPI number — SD HEALTHCARE RX NC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SD HEALTHCARE RX NC
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:
1053490797
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3030 CHILDRENS WAY
Provider Second Line Business Mailing Address:
#108
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92123-4232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-966-4060
Provider Business Mailing Address Fax Number:
858-966-5995

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3030 CHILDRENS WAY
Provider Second Line Business Practice Location Address:
#108
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-4232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-966-4060
Provider Business Practice Location Address Fax Number:
858-966-5995
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
PARESH
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO/DIRECTOR
Authorized Official Telephone Number:
858-966-4060

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY371130 , 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: PHA371130 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0518867 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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