Provider Demographics
NPI:1326125295
Name:IRVINE MEDICAL PHARMACY INC
Entity Type:Organization
Organization Name:IRVINE MEDICAL PHARMACY INC
Other - Org Name:IRVINE MEDICAL PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:NASSER
Authorized Official - Middle Name:
Authorized Official - Last Name:FATHI
Authorized Official - Suffix:
Authorized Official - Credentials:PHRM
Authorized Official - Phone:949-552-7777
Mailing Address - Street 1:14130 CULVER DR
Mailing Address - Street 2:STE D
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-0314
Mailing Address - Country:US
Mailing Address - Phone:949-552-7777
Mailing Address - Fax:949-552-7292
Practice Address - Street 1:14130 CULVER DR
Practice Address - Street 2:STE D
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-0314
Practice Address - Country:US
Practice Address - Phone:949-552-7777
Practice Address - Fax:949-552-7292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
CAPHY420463336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0568634OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA420460Medicaid