1609974005 NPI number — BWWNGC INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609974005 NPI number — BWWNGC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BWWNGC 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:
1609974005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7824 GIRARD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-4230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-459-4285
Provider Business Mailing Address Fax Number:
858-459-9521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7824 GIRARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-4230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-459-4285
Provider Business Practice Location Address Fax Number:
858-459-9521
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOODS
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-459-4285

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY37018 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PHA370180 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0514845 . This is a "NABP" identifier . This identifiers is of the category "OTHER".
  • Identifier: PHY37018 . This is a "STATE PHARMACY LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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