Provider Demographics
NPI:1659465912
Name:COUNTRY VILLAGE PHARMACY
Entity Type:Organization
Organization Name:COUNTRY VILLAGE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ARSHAD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:951-681-8889
Mailing Address - Street 1:10251 COUNTRY CLUB DR
Mailing Address - Street 2:STE B
Mailing Address - City:MIRA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91752-1329
Mailing Address - Country:US
Mailing Address - Phone:951-681-8889
Mailing Address - Fax:951-681-2948
Practice Address - Street 1:10251 COUNTRY CLUB DR
Practice Address - Street 2:STE B
Practice Address - City:MIRA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91752-1329
Practice Address - Country:US
Practice Address - Phone:951-681-8889
Practice Address - Fax:951-681-2948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY341663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1997702OtherPK
CAPHA341660Medicaid
CAPHA341660Medicaid