Provider Demographics
NPI:1568473155
Name:PENASQUITOS PHARMACY
Entity Type:Organization
Organization Name:PENASQUITOS PHARMACY
Other - Org Name:PENASQUITOS PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BURDENHOLZER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:858-484-2880
Mailing Address - Street 1:9917 CARMEL MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9917 CARMEL MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2813
Practice Address - Country:US
Practice Address - Phone:858-484-2880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY32769333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA327690Medicaid
0570110OtherOTHER ID NUMBER-COMMERCIAL NUMBER