Provider Demographics
NPI:1518029321
Name:REDLANDS PHARMACY INC
Entity Type:Organization
Organization Name:REDLANDS PHARMACY INC
Other - Org Name:REDLANDS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHU
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:909-792-8118
Mailing Address - Street 1:245 TERRACINA BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4867
Mailing Address - Country:US
Mailing Address - Phone:909-792-8118
Mailing Address - Fax:909-793-7331
Practice Address - Street 1:245 TERRACINA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4867
Practice Address - Country:US
Practice Address - Phone:909-792-8118
Practice Address - Fax:909-793-7331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY487753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA487750Medicaid
2113323OtherPK
2113323OtherPK