Provider Demographics
NPI:1689271066
Name:INNOVA PHARMACY IV
Entity Type:Organization
Organization Name:INNOVA PHARMACY IV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:THIEN
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:916-220-3344
Mailing Address - Street 1:2400 GLENDALE LN STE A
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2431
Mailing Address - Country:US
Mailing Address - Phone:916-487-9977
Mailing Address - Fax:
Practice Address - Street 1:4815 WATT AVE STE B101
Practice Address - Street 2:
Practice Address - City:NORTH HIGHLANDS
Practice Address - State:CA
Practice Address - Zip Code:95660-5108
Practice Address - Country:US
Practice Address - Phone:916-220-3344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy