Provider Demographics
NPI:1578748877
Name:IRDGAS
Entity Type:Organization
Organization Name:IRDGAS
Other - Org Name:SERRA MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:MANZANI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:818-768-3322
Mailing Address - Street 1:9375 SAN FERNANDO RD
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-1418
Mailing Address - Country:US
Mailing Address - Phone:818-768-3322
Mailing Address - Fax:818-504-0418
Practice Address - Street 1:9375 SAN FERNANDO RD
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-1418
Practice Address - Country:US
Practice Address - Phone:818-768-3322
Practice Address - Fax:818-504-0418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY4062103336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA406210Medicaid
CAPHA406210Medicaid