Provider Demographics
NPI:1164776191
Name:SAN DIEGO COMMUNITY PHARMACY
Entity Type:Organization
Organization Name:SAN DIEGO COMMUNITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:OLLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:619-249-8623
Mailing Address - Street 1:3703 CAMINO DEL RIO S STE 215B
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4032
Mailing Address - Country:US
Mailing Address - Phone:619-249-8623
Mailing Address - Fax:
Practice Address - Street 1:3703 CAMINO DEL RIO S STE 215B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4032
Practice Address - Country:US
Practice Address - Phone:619-249-8623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA102302979OtherCA BOARD OF EQUALIZATION - SELLERS PERMIT
CA20129010027OtherCA SECRETARY OF STATE