Provider Demographics
NPI:1568529915
Name:INNOVA PHARMACEUTICALS INC
Entity Type:Organization
Organization Name:INNOVA PHARMACEUTICALS INC
Other - Org Name:INNOVA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:T
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:916-481-6900
Mailing Address - Street 1:5830 JAMESON CT
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0896
Mailing Address - Country:US
Mailing Address - Phone:916-481-6900
Mailing Address - Fax:916-481-6680
Practice Address - Street 1:5830 JAMESON CT
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0896
Practice Address - Country:US
Practice Address - Phone:916-481-6900
Practice Address - Fax:916-481-6680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
CAPHY486173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0589703OtherOTHER ID NUMBER
CA1568529915Medicaid
0589703OtherOTHER ID NUMBER