Provider Demographics
NPI:1477734507
Name:SPECIALTY MEDICAL
Entity Type:Organization
Organization Name:SPECIALTY MEDICAL
Other - Org Name:SPECIALTY MEDICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:D
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-688-5326
Mailing Address - Street 1:2680 POMONA BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3272
Mailing Address - Country:US
Mailing Address - Phone:626-688-5326
Mailing Address - Fax:800-619-6826
Practice Address - Street 1:2680 POMONA BLVD STE B
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3272
Practice Address - Country:US
Practice Address - Phone:626-688-5326
Practice Address - Fax:626-599-2025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25251332B00000X
CAPHY420983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA420980Medicaid
CAPHA420980Medicaid