1790116861 NPI number — MARAVICH ENTERPRISES

Table of content: (NPI 1790116861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790116861 NPI number — MARAVICH ENTERPRISES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARAVICH ENTERPRISES
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:
HIDDEN VALLEY 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:
1790116861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19851 HARTMANN RD
Provider Second Line Business Mailing Address:
UNIT C
Provider Business Mailing Address City Name:
HIDDEN VALLEY LAKE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95467-8307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-987-3995
Provider Business Mailing Address Fax Number:
707-987-3120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19851 HARTMANN RD
Provider Second Line Business Practice Location Address:
UNIT C
Provider Business Practice Location Address City Name:
HIDDEN VALLEY LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95467-8307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-987-3995
Provider Business Practice Location Address Fax Number:
707-987-3120
Provider Enumeration Date:
11/27/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MARAVICH
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
707-987-3995

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY51432 , 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: 3765640 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2143179 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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