Provider Demographics
NPI:1275633224
Name:REGENTS UNIV OF CALIF LOS ANGELES
Entity Type:Organization
Organization Name:REGENTS UNIV OF CALIF LOS ANGELES
Other - Org Name:RONALD REAGAN UCLA - MEDICAL PLAZA LEVEL I PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO UCLA HOSPITAL SYSTEM
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-794-8627
Mailing Address - Street 1:PHARMACY BUSINESS OFC
Mailing Address - Street 2:757 WESTWOOD PLAZA, ROOM B504E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-7423
Mailing Address - Country:US
Mailing Address - Phone:310-267-8517
Mailing Address - Fax:310-267-3644
Practice Address - Street 1:200 UCLA MEDICAL PLZ
Practice Address - Street 2:SUITE 135
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-6949
Practice Address - Country:US
Practice Address - Phone:310-794-1176
Practice Address - Fax:310-794-1187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
CAPHE409773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1275633224Medicaid
1992432OtherPK
CAPH0000235Medicaid