Provider Demographics
NPI:1386212629
Name:PORTERVILLE EXPRESS SPECIALTY PHARMACY, LLC
Entity Type:Organization
Organization Name:PORTERVILLE EXPRESS SPECIALTY PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:ANAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BAYTAMOUNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-364-3033
Mailing Address - Street 1:301 E OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-4871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 E OLIVE AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-4871
Practice Address - Country:US
Practice Address - Phone:559-364-3033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy