1609904119 NPI number — IRVINE SAND CANYON PHARMACY INC

Table of content: (NPI 1609904119)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609904119 NPI number — IRVINE SAND CANYON PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IRVINE SAND CANYON 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:
TOWN CENTER COMPOUNDING 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:
1609904119
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:
8 SCARBOROUGH WAY
Provider Second Line Business Mailing Address:
ROOM 92270
Provider Business Mailing Address City Name:
RANCHO MIRAGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92270-1624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-880-2537
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
72624 EL PASEO
Provider Second Line Business Practice Location Address:
SUITE A1
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92260-3309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-341-3984
Provider Business Practice Location Address Fax Number:
760-341-4954
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FARINA
Authorized Official First Name:
MORT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-880-2537

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X , with the licence number:  99148 , 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: 44047 . This is a "PHARMACY LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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