1154453413 NPI number — SANTA ANA HEALTH CLINIC PHARMACY

Table of content: (NPI 1154453413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154453413 NPI number — SANTA ANA HEALTH CLINIC PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANTA ANA HEALTH CLINIC PHARMACY
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:
1154453413
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 95458
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44101-0033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-248-7771
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
02 C DOVE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERNALILLO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-867-2497
Provider Business Practice Location Address Fax Number:
505-867-1526
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
DARRELL
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
505-248-7773

Provider Taxonomy Codes

  • Taxonomy code: 332800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3209271 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11237 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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