Provider Demographics
NPI:1154445179
Name:DELTA DRUGS
Entity Type:Organization
Organization Name:DELTA DRUGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:TENETTE
Authorized Official - Suffix:
Authorized Official - Credentials:RPN
Authorized Official - Phone:909-887-2596
Mailing Address - Street 1:1666 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1257
Mailing Address - Country:US
Mailing Address - Phone:909-887-2596
Mailing Address - Fax:909-887-8496
Practice Address - Street 1:1666 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1257
Practice Address - Country:US
Practice Address - Phone:909-887-2596
Practice Address - Fax:909-887-8496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY374503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA374500Medicaid