Provider Demographics
NPI:1235622945
Name:RUHS-CORONA PHARMACY
Entity Type:Organization
Organization Name:RUHS-CORONA PHARMACY
Other - Org Name:RUHS-CORONA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:DAVALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-486-4527
Mailing Address - Street 1:26520 CACTUS AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3927
Mailing Address - Country:US
Mailing Address - Phone:951-486-4761
Mailing Address - Fax:
Practice Address - Street 1:2813 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-5942
Practice Address - Country:US
Practice Address - Phone:951-955-0111
Practice Address - Fax:951-486-4540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X
CA560923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177826OtherPK