Provider Demographics
NPI:1194825265
Name:IMGRX SJ VALLEY, INC.
Entity Type:Organization
Organization Name:IMGRX SJ VALLEY, INC.
Other - Org Name:UNITED HEALTH CENTERS PHARMACY ORANGE COVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, MANAGED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-749-4764
Mailing Address - Street 1:ATTN: CHC RETAIL PHARMACY DEPT. 13651 DUBLIN CT
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477
Mailing Address - Country:US
Mailing Address - Phone:281-749-4000
Mailing Address - Fax:614-652-0326
Practice Address - Street 1:445 11TH STREET
Practice Address - Street 2:
Practice Address - City:ORANGE COVE
Practice Address - State:CA
Practice Address - Zip Code:93646
Practice Address - Country:US
Practice Address - Phone:559-626-4031
Practice Address - Fax:559-626-5070
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMGRX SJ VALLEY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-25
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY545183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA198020Medicaid