Provider Demographics
NPI:1053490797
Name:RADY CHILDREN'S HEALTH SERVICES-SAN DIEGO
Entity Type:Organization
Organization Name:RADY CHILDREN'S HEALTH SERVICES-SAN DIEGO
Other - Org Name:CHILDREN'S MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CAIN CARRITHERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-576-1700
Mailing Address - Street 1:3030 CHILDRENS WAY
Mailing Address - Street 2:STE 108
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4232
Mailing Address - Country:US
Mailing Address - Phone:858-966-4060
Mailing Address - Fax:858-966-5995
Practice Address - Street 1:3030 CHILDRENS WAY
Practice Address - Street 2:STE 108
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4232
Practice Address - Country:US
Practice Address - Phone:858-966-4060
Practice Address - Fax:858-966-5995
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADY CHILDREN'S HOSPITAL - SAN DIEGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-03
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY3711303336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0518867OtherNCPDP
CAPHA371130Medicaid
CAPHA371130Medicaid