Provider Demographics
NPI:1033124664
Name:MESA PHARMACY
Entity Type:Organization
Organization Name:MESA PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MYTU
Authorized Official - Middle Name:
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-425-2706
Mailing Address - Street 1:14085 NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-5172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14085 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-5172
Practice Address - Country:US
Practice Address - Phone:714-505-2231
Practice Address - Fax:714-505-2235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY47404333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5618244OtherOTHER ID NUMBER-COMMERCIAL NUMBER