Provider Demographics
NPI:1568004174
Name:CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY-STATE PRISON
Entity Type:Organization
Organization Name:CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY-STATE PRISON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:ROSENBLATT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:559-992-7100
Mailing Address - Street 1:900 QUEBEC AVE
Mailing Address - Street 2:
Mailing Address - City:CORCORAN
Mailing Address - State:CA
Mailing Address - Zip Code:93212-9715
Mailing Address - Country:US
Mailing Address - Phone:559-992-7100
Mailing Address - Fax:559-992-7201
Practice Address - Street 1:900 QUEBEC AVE
Practice Address - Street 2:
Practice Address - City:CORCORAN
Practice Address - State:CA
Practice Address - Zip Code:93212-9715
Practice Address - Country:US
Practice Address - Phone:559-992-7100
Practice Address - Fax:559-992-7201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCF43147Medicaid