Provider Demographics
NPI:1083727960
Name:FOUNTAIN VALLEY REGIONAL HOSPITAL AND MEDICAL CENTER
Entity Type:Organization
Organization Name:FOUNTAIN VALLEY REGIONAL HOSPITAL AND MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY CLINICAL MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:UNG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:714-966-7217
Mailing Address - Street 1:17100 EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4004
Mailing Address - Country:US
Mailing Address - Phone:714-966-7217
Mailing Address - Fax:714-966-3337
Practice Address - Street 1:11100 WARNER AVE
Practice Address - Street 2:SUITE 318
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7506
Practice Address - Country:US
Practice Address - Phone:714-966-7217
Practice Address - Fax:714-966-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA445461835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Single Specialty