Provider Demographics
NPI:1659491389
Name:DIGNITY HEALTH
Entity Type:Organization
Organization Name:DIGNITY HEALTH
Other - Org Name:MERCY MT. SHASTA INPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-225-6121
Mailing Address - Street 1:914 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2143
Mailing Address - Country:US
Mailing Address - Phone:530-926-6111
Mailing Address - Fax:530-225-7278
Practice Address - Street 1:914 PINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2143
Practice Address - Country:US
Practice Address - Phone:530-926-6111
Practice Address - Fax:530-225-7278
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIGNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-29
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHSP455273336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0596657OtherNCPDP
CAPHB331890Medicaid