Provider Demographics
NPI:1346667268
Name:CALIFORNIA INSTITUE FOR MEN
Entity Type:Organization
Organization Name:CALIFORNIA INSTITUE FOR MEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST INCHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:KERIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BANGOU
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:909-597-1821
Mailing Address - Street 1:14901 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-9500
Mailing Address - Country:US
Mailing Address - Phone:909-597-1821
Mailing Address - Fax:909-606-4332
Practice Address - Street 1:14901 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-9500
Practice Address - Country:US
Practice Address - Phone:909-597-1821
Practice Address - Fax:909-606-4332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44274273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA44274OtherPHARMACIST LICENCE NUMBER