Provider Demographics
NPI:1164550885
Name:PACIFIC PHARMACY GROUP
Entity Type:Organization
Organization Name:PACIFIC PHARMACY GROUP
Other - Org Name:NEWPORT LIDO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-764-6580
Mailing Address - Street 1:351 HOSPITAL RD
Mailing Address - Street 2:STE 107
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3509
Mailing Address - Country:US
Mailing Address - Phone:949-764-6580
Mailing Address - Fax:949-764-6581
Practice Address - Street 1:351 HOSPITAL RD
Practice Address - Street 2:STE 107
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3594
Practice Address - Country:US
Practice Address - Phone:949-764-6580
Practice Address - Fax:949-764-6581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY499873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1164550885Medicaid
2121543OtherPK
CA1164550885Medicaid