Provider Demographics
NPI:1457483083
Name:CSU DOMINGUEZ HILLS PHARMACY
Entity Type:Organization
Organization Name:CSU DOMINGUEZ HILLS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:
Authorized Official - Last Name:FUGAMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-243-3194
Mailing Address - Street 1:1000 E VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90747-0001
Mailing Address - Country:US
Mailing Address - Phone:310-243-3194
Mailing Address - Fax:310-243-6990
Practice Address - Street 1:1000 E VICTORIA ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90747-0001
Practice Address - Country:US
Practice Address - Phone:310-243-3194
Practice Address - Fax:310-243-6990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health