Provider Demographics
NPI:1275852758
Name:MDMX CORPORATION
Entity Type:Organization
Organization Name:MDMX CORPORATION
Other - Org Name:CORONA SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESDIENT/ PIC
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MAHEALANI
Authorized Official - Last Name:AHN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:951-278-1008
Mailing Address - Street 1:1280 CORONA POINTE CT
Mailing Address - Street 2:STE 114
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-1770
Mailing Address - Country:US
Mailing Address - Phone:951-278-1008
Mailing Address - Fax:951-278-1009
Practice Address - Street 1:1280 CORONA POINTE CT
Practice Address - Street 2:STE 114
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1770
Practice Address - Country:US
Practice Address - Phone:951-278-1008
Practice Address - Fax:951-278-1009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY 50310333600000X, 3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY 50310OtherRETAIL PHARMACY PERMIT