Provider Demographics
NPI:1629027867
Name:CORAM HEALTHCARE CORPORATION OF NORTHERN CALIFORNIA
Entity Type:Organization
Organization Name:CORAM HEALTHCARE CORPORATION OF NORTHERN CALIFORNIA
Other - Org Name:CORAM CVS/SPECIALTY INFUSION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LACAVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-306-3255
Mailing Address - Street 1:PO BOX 809160
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-9160
Mailing Address - Country:US
Mailing Address - Phone:480-765-5043
Mailing Address - Fax:401-733-0211
Practice Address - Street 1:1401 WILLOW PASS RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-7982
Practice Address - Country:US
Practice Address - Phone:323-371-5046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORAM HEALTHCARE CORP OF NORTHERN CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020000338251E00000X, 251F00000X
CA261QI0500X
CAPHY49294332B00000X
CAPHY 46636332BP3500X, 333600000X, 3336C0003X, 3336M0002X, 3336H0001X
3336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No251E00000XAgenciesHome Health
Yes251F00000XAgenciesHome Infusion
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY49294OtherPHARMACY LICENSE
CA020000338OtherHOME HEALTH AGENCY
0522385OtherNCPDP
CAPHA466360Medicaid
BC4820519OtherDEA
0522385OtherNCPDP
CAPHA378581Medicare ID - Type UnspecifiedPART B LOCAL