Provider Demographics
NPI:1043445208
Name:SAI BEAR CREEK PHARMACY LLC
Entity Type:Organization
Organization Name:SAI BEAR CREEK PHARMACY LLC
Other - Org Name:BEAR CREEK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAISATISH
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-677-4880
Mailing Address - Street 1:24046 CLINTON KEITH RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595
Mailing Address - Country:US
Mailing Address - Phone:951-677-4880
Mailing Address - Fax:951-698-4392
Practice Address - Street 1:24046 CLINTON KEITH RD
Practice Address - Street 2:SUITE 107
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595
Practice Address - Country:US
Practice Address - Phone:951-677-4880
Practice Address - Fax:951-698-4392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
CA506783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131358OtherPK
CA1043445208Medicaid