Provider Demographics
NPI:1679677629
Name:LONG BEACH MEMORIAL MEDICAL
Entity Type:Organization
Organization Name:LONG BEACH MEMORIAL MEDICAL
Other - Org Name:INFUSION CARE PHARMACY SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FINCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-377-3218
Mailing Address - Street 1:PO BOX 20359
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90801-3359
Mailing Address - Country:US
Mailing Address - Phone:562-933-3282
Mailing Address - Fax:562-933-0014
Practice Address - Street 1:23521 PASEO DE VALENCIA
Practice Address - Street 2:STE B-1
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653
Practice Address - Country:US
Practice Address - Phone:949-460-1610
Practice Address - Fax:949-458-0554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BP3500X, 3336C0003X
CAPHY405303336H0001X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA40530Medicaid
1996335OtherPK
CA0310340003Medicare NSC