Provider Demographics
NPI:1518015510
Name:COVINA PHARMACY INC
Entity Type:Organization
Organization Name:COVINA PHARMACY INC
Other - Org Name:COVINA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHRM
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-915-6615
Mailing Address - Street 1:174 W BADILLO ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-2015
Mailing Address - Country:US
Mailing Address - Phone:626-915-6615
Mailing Address - Fax:626-339-6357
Practice Address - Street 1:174 W BADILLO ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-2015
Practice Address - Country:US
Practice Address - Phone:626-915-6615
Practice Address - Fax:626-339-6357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY311673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA311670Medicaid
0582557OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0876080001Medicare NSC