Provider Demographics
NPI:1104842020
Name:UNIVERSITY OF CALIFORNIA IRVINE
Entity Type:Organization
Organization Name:UNIVERSITY OF CALIFORNIA IRVINE
Other - Org Name:OUTPATIENT PHARMACY - UC IRVINE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REIMBURSEMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURCHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-509-6266
Mailing Address - Street 1:1500 S DOUGLASS RD #200, RT 183
Mailing Address - Street 2:
Mailing Address - City:AHANEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-6912
Mailing Address - Country:US
Mailing Address - Phone:714-509-6266
Mailing Address - Fax:
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-6604
Practice Address - Fax:714-509-2200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHE554873336S0011X
CAPHE498193336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2066998OtherPK
CAPHB22716Medicaid