Provider Demographics
NPI:1083945240
Name:SADDLEBACK MEDICAL ARTS PHARMACY INC
Entity Type:Organization
Organization Name:SADDLEBACK MEDICAL ARTS PHARMACY INC
Other - Org Name:SADDLEBACK MEDICAL ARTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / PIC
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SILAHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:949-581-9840
Mailing Address - Street 1:24953 PASEO DE VALENCIA
Mailing Address - Street 2:#17-B
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-4342
Mailing Address - Country:US
Mailing Address - Phone:949-581-9840
Mailing Address - Fax:949-770-7545
Practice Address - Street 1:24953 PASEO DE VALENCIA
Practice Address - Street 2:#17-B
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4342
Practice Address - Country:US
Practice Address - Phone:949-581-9840
Practice Address - Fax:949-770-7545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA501453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
6477390001Medicare NSC