Provider Demographics
NPI:1508972456
Name:PROVIDENCE HEALTH SYSTEM-SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM-SOUTHERN CALIFORNIA
Other - Org Name:PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY OF ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:1300 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3505
Mailing Address - Country:US
Mailing Address - Phone:310-514-5267
Mailing Address - Fax:310-514-5462
Practice Address - Street 1:1300 W 7TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3505
Practice Address - Country:US
Practice Address - Phone:310-832-3311
Practice Address - Fax:310-514-5462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHSP472263336I0012X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHB472260Medicaid
0544519OtherNCPDP PROVIDER IDENTIFICATION NUMBER
050078Medicare Oscar/Certification