Provider Demographics
NPI:1669829628
Name:IMGRX SALUD INC
Entity Type:Organization
Organization Name:IMGRX SALUD INC
Other - Org Name:EL DORADO COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, MANAGED SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-749-4764
Mailing Address - Street 1:ATTN: CHC RETAIL PHARMACY DEPT. 13651 DUBLIN CT
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477
Mailing Address - Country:US
Mailing Address - Phone:281-749-4000
Mailing Address - Fax:614-652-0326
Practice Address - Street 1:3104 PONTE MORINO DR STE 100
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8282
Practice Address - Country:US
Practice Address - Phone:530-556-2007
Practice Address - Fax:530-350-6331
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMGRX SALUD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-19
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA545383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2163628OtherPK