Provider Demographics
NPI:1558321307
Name:CHILDREN'S HOSPITAL CENTRAL CALIFORNIA CAMPUS PHARMACY
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL CENTRAL CALIFORNIA CAMPUS PHARMACY
Other - Org Name:VALLEY CHILDREN'S CAMPUS PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:INOUYE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:559-353-6302
Mailing Address - Street 1:41169 GOODWIN WAY
Mailing Address - Street 2:MAIL STOP MB09
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-8766
Mailing Address - Country:US
Mailing Address - Phone:559-353-6300
Mailing Address - Fax:559-353-6308
Practice Address - Street 1:41169 GOODWIN WAY
Practice Address - Street 2:MAIL STOP MB09
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-8766
Practice Address - Country:US
Practice Address - Phone:559-353-6300
Practice Address - Fax:559-353-6308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY437930333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0537639OtherNABP #
CAPHY437930Medicaid
CAPHY437930Medicaid