Provider Demographics
NPI:1306372891
Name:BOLSA MEDICAL MTM PHARMA INC
Entity Type:Organization
Organization Name:BOLSA MEDICAL MTM PHARMA INC
Other - Org Name:MTM PHARMACY IV
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / PHARMACIST IN CHARGE
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA TUYET
Authorized Official - Middle Name:
Authorized Official - Last Name:QUACH-TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-916-5383
Mailing Address - Street 1:6552 BOLSA AVE
Mailing Address - Street 2:STE A
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-2660
Mailing Address - Country:US
Mailing Address - Phone:714-916-5383
Mailing Address - Fax:714-916-5384
Practice Address - Street 1:6552 BOLSA AVE STE A
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-2656
Practice Address - Country:US
Practice Address - Phone:714-916-5383
Practice Address - Fax:714-916-5384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3622641Medicaid
CAPHY57954OtherBOARD OF PHARMACY