Provider Demographics
NPI:1629140405
Name:PATHWAY PHARMACEUTICALS INC
Entity Type:Organization
Organization Name:PATHWAY PHARMACEUTICALS INC
Other - Org Name:FIRESIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADEYEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:OMILANA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:760-409-4898
Mailing Address - Street 1:73847 HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-4005
Mailing Address - Country:US
Mailing Address - Phone:760-346-1113
Mailing Address - Fax:760-346-8725
Practice Address - Street 1:73847 HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-4005
Practice Address - Country:US
Practice Address - Phone:760-346-1113
Practice Address - Fax:760-346-8725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336H0001X, 3336S0011X
CAPHY474073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA474070Medicaid
2067075OtherPK
4919170002Medicare NSC