Provider Demographics
NPI:1154306231
Name:SOLARA MEDICAL SUPPLIES, LLC
Entity Type:Organization
Organization Name:SOLARA MEDICAL SUPPLIES, LLC
Other - Org Name:IMPERIAL BEACH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TOD
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-259-8287
Mailing Address - Street 1:2084 OTAY LAKES RD STE 102
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1368
Mailing Address - Country:US
Mailing Address - Phone:800-999-7516
Mailing Address - Fax:800-999-7021
Practice Address - Street 1:720 HWY 75
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932
Practice Address - Country:US
Practice Address - Phone:619-424-8143
Practice Address - Fax:619-424-8652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-12
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CAPHY46235333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA462350Medicaid
CAPHA462350Medicaid