Provider Demographics
NPI:1033321427
Name:HACIENDA COLIMA INVESTMENT INC.
Entity Type:Organization
Organization Name:HACIENDA COLIMA INVESTMENT INC.
Other - Org Name:HACIENDA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:KAIWAI
Authorized Official - Last Name:HO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, CDM DIABETES
Authorized Official - Phone:626-330-8832
Mailing Address - Street 1:3120 S HACIENDA BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6305
Mailing Address - Country:US
Mailing Address - Phone:626-330-8832
Mailing Address - Fax:626-330-9661
Practice Address - Street 1:3120 S HACIENDA BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-6305
Practice Address - Country:US
Practice Address - Phone:626-330-8832
Practice Address - Fax:626-330-9661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6092360001332B00000X
CAPHY484403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6092360001Medicare NSC