Provider Demographics
NPI:1407898265
Name:SUTTER CENTRAL VALLEY HOSPITALS
Entity Type:Organization
Organization Name:SUTTER CENTRAL VALLEY HOSPITALS
Other - Org Name:MEMORIAL MEDICAL CENTER OPT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP SHARED SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:TRENT
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-297-8555
Mailing Address - Street 1:PO BOX 740152
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0152
Mailing Address - Country:US
Mailing Address - Phone:855-398-1633
Mailing Address - Fax:209-569-7362
Practice Address - Street 1:1800 COFFEE ROAD
Practice Address - Street 2:STE. 110
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2803
Practice Address - Country:US
Practice Address - Phone:209-569-7642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHSP37596251F00000X, 332BP3500X, 3336C0003X, 3336H0001X
CA030000061282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No251F00000XAgenciesHome Infusion
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
050557OtherBLUE CROSS
CAPHB375960Medicaid
CA0538009OtherNABP
CA0538009OtherNCPDP
CA0998490001Medicare NSC
CA0538009OtherNABP