Provider Demographics
NPI:1275684474
Name:FOUNTAIN VALLEY CANCER CENTER PHARMACY
Entity Type:Organization
Organization Name:FOUNTAIN VALLEY CANCER CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:HORWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:714-979-3784
Mailing Address - Street 1:11190 WARNER AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4019
Mailing Address - Country:US
Mailing Address - Phone:714-979-3784
Mailing Address - Fax:714-436-9217
Practice Address - Street 1:11190 WARNER AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4019
Practice Address - Country:US
Practice Address - Phone:714-979-3784
Practice Address - Fax:714-436-9217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY432743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA432740Medicaid
CAPHA432740Medicaid