Provider Demographics
NPI:1154332658
Name:PACIFICA FORTUNA INC
Entity Type:Organization
Organization Name:PACIFICA FORTUNA INC
Other - Org Name:PACIFICA FORTUNA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-892-8388
Mailing Address - Street 1:14427 CHASE ST
Mailing Address - Street 2:STE B
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-3020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14427 CHASE ST
Practice Address - Street 2:STE B
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-3020
Practice Address - Country:US
Practice Address - Phone:818-892-8388
Practice Address - Fax:818-892-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CAPHY465933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA465930Medicaid
5601566OtherOTHER ID NUMBER
5172240001Medicare NSC