Provider Demographics
NPI:1578684395
Name:TUSTIN HOSPITAL AND MEDICAL CENTER
Entity Type:Organization
Organization Name:TUSTIN HOSPITAL AND MEDICAL CENTER
Other - Org Name:TUSTIN HOSPITAL AND MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FAREED
Authorized Official - Middle Name:
Authorized Official - Last Name:ENTEZAR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:714-669-5874
Mailing Address - Street 1:14662 NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14662 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6064
Practice Address - Country:US
Practice Address - Phone:714-669-5874
Practice Address - Fax:714-669-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHSP433753336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHB499750Medicaid
0555322OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHB433750Medicaid