1750491577 NPI number — SPRING VALLEY LAKE PHARMACY INC

Table of content: (NPI 1750491577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750491577 NPI number — SPRING VALLEY LAKE PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRING VALLEY LAKE 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:
A FAMILY 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:
1750491577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9778 SVL BOX
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VICTORVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92395-5142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-244-3777
Provider Business Mailing Address Fax Number:
760-244-2845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11919 HESPERIA RD
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
HESPERIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92345-2158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-244-3777
Provider Business Practice Location Address Fax Number:
760-242-8617
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ATTIA
Authorized Official First Name:
RAAFAT
Authorized Official Middle Name:
FAYEZ
Authorized Official Title or Position:
PRESIDENT/PIC
Authorized Official Telephone Number:
760-244-3777

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY51251 , 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: 5614020 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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