Provider Demographics
NPI:1275884736
Name:PALOMAR HEALTH
Entity Type:Organization
Organization Name:PALOMAR HEALTH
Other - Org Name:PALOMAR HEALTH OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-740-6385
Mailing Address - Street 1:2125 CITRACADO PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-4159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:760-489-9908
Practice Address - Street 1:2185 CITRACADO PKWY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-4159
Practice Address - Country:US
Practice Address - Phone:442-281-4000
Practice Address - Fax:760-489-9908
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALOMAR HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-25
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CA519493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147435OtherPK
CA071PHA511240Medicaid
0483391425Medicare NSC