Provider Demographics
NPI:1659797421
Name:MTM PHARMA INC
Entity Type:Organization
Organization Name:MTM PHARMA INC
Other - Org Name:PROFESSIONAL PHARMACY SANTA ANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:T
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:714-278-4800
Mailing Address - Street 1:2339 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-3503
Mailing Address - Country:US
Mailing Address - Phone:714-278-4800
Mailing Address - Fax:714-278-4769
Practice Address - Street 1:2339 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-3503
Practice Address - Country:US
Practice Address - Phone:714-278-4800
Practice Address - Fax:714-278-4769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2023-07-07
Deactivation Date:2021-09-01
Deactivation Code:
Reactivation Date:2021-09-14
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY 518233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY51823OtherBOARD OF PHARMACY
CA1659797421Medicaid