Provider Demographics
NPI:1609904119
Name:IRVINE SAND CANYON PHARMACY INC
Entity Type:Organization
Organization Name:IRVINE SAND CANYON PHARMACY INC
Other - Org Name:TOWN CENTER COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MORT
Authorized Official - Middle Name:
Authorized Official - Last Name:FARINA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:310-880-2537
Mailing Address - Street 1:8 SCARBOROUGH WAY
Mailing Address - Street 2:ROOM 92270
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1624
Mailing Address - Country:US
Mailing Address - Phone:310-880-2537
Mailing Address - Fax:
Practice Address - Street 1:72624 EL PASEO
Practice Address - Street 2:SUITE A1
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3309
Practice Address - Country:US
Practice Address - Phone:760-341-3984
Practice Address - Fax:760-341-4954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA991483336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA44047OtherPHARMACY LICENSE