Provider Demographics
NPI:1639190606
Name:STATE OF CALIFORNIA
Entity Type:Organization
Organization Name:STATE OF CALIFORNIA
Other - Org Name:STUDENT HLTH SRVC CSU LONG BCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-985-1561
Mailing Address - Street 1:1250 N BELLFLOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90840-0004
Mailing Address - Country:US
Mailing Address - Phone:562-985-1561
Mailing Address - Fax:562-985-8404
Practice Address - Street 1:1250 N BELLFLOWER BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90840-0004
Practice Address - Country:US
Practice Address - Phone:562-985-1561
Practice Address - Fax:562-985-8404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHE142173336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA142170Medicaid
0534974OtherNCPDP PROVIDER IDENTIFICATION NUMBER