Provider Demographics
NPI:1124041272
Name:UNIVERSITY OF CALIFORNIA IRVINE
Entity Type:Organization
Organization Name:UNIVERSITY OF CALIFORNIA IRVINE
Other - Org Name:UCI FAMILY HEALTH CENTER PHARMACY
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:ANAHEIM
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 1:800 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-3576
Practice Address - Country:US
Practice Address - Phone:714-456-6785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF CALIFORNIA IRVINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-26
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEXEMPT3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0564028OtherS.A. NABP#
CAPHA413170Medicaid