Provider Demographics
NPI:1609924604
Name:GARRICK SHUM
Entity Type:Organization
Organization Name:GARRICK SHUM
Other - Org Name:FISHERS BREA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-925-2622
Mailing Address - Street 1:385 W CENTRAL AVE
Mailing Address - Street 2:STE E
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3000
Mailing Address - Country:US
Mailing Address - Phone:714-529-2113
Mailing Address - Fax:714-529-5614
Practice Address - Street 1:385 W CENTRAL AVE
Practice Address - Street 2:STE E
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3000
Practice Address - Country:US
Practice Address - Phone:714-529-2113
Practice Address - Fax:714-529-5614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY487603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0505632OtherOTHER ID NUMBER
0505632OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHA454610Medicaid
CAPHA454610Medicaid