Provider Demographics
NPI:1598903130
Name:PHARMA NOVA INC
Entity Type:Organization
Organization Name:PHARMA NOVA INC
Other - Org Name:PARKSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTEGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-224-6027
Mailing Address - Street 1:4404 DEL RIO RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-1126
Mailing Address - Country:US
Mailing Address - Phone:916-452-2200
Mailing Address - Fax:916-452-2247
Practice Address - Street 1:4404 DEL RIO RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95822-1126
Practice Address - Country:US
Practice Address - Phone:916-452-2200
Practice Address - Fax:916-452-2247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA492893336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5633638OtherNCPDP PROVIDER IDENTIFICATION NUMBER