Provider Demographics
NPI:1508094558
Name:MODERNHEALTH HOLDINGS INC
Entity Type:Organization
Organization Name:MODERNHEALTH HOLDINGS INC
Other - Org Name:MODERN HEALTH PHARMACY - SD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-932-1721
Mailing Address - Street 1:110 E HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-3415
Mailing Address - Country:US
Mailing Address - Phone:858-668-3350
Mailing Address - Fax:858-668-3352
Practice Address - Street 1:13220 EVENING CREEK DR S
Practice Address - Street 2:STE 110
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-4103
Practice Address - Country:US
Practice Address - Phone:858-668-3350
Practice Address - Fax:858-668-3352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY510023336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121362OtherPK
CA1508094558Medicaid
6706700001Medicare NSC