Provider Demographics
NPI:1689927816
Name:IVANHOE PHARMACY INC
Entity Type:Organization
Organization Name:IVANHOE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:DERDERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD; RPH
Authorized Official - Phone:559-798-1219
Mailing Address - Street 1:33060 ROAD 159
Mailing Address - Street 2:
Mailing Address - City:IVANHOE
Mailing Address - State:CA
Mailing Address - Zip Code:93235-1235
Mailing Address - Country:US
Mailing Address - Phone:559-798-1219
Mailing Address - Fax:559-798-0975
Practice Address - Street 1:33060 ROAD 159
Practice Address - Street 2:
Practice Address - City:IVANHOE
Practice Address - State:CA
Practice Address - Zip Code:93235-1235
Practice Address - Country:US
Practice Address - Phone:559-798-1219
Practice Address - Fax:559-798-0975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY511383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689927816Medicaid
CA5645683OtherNCPDP
CA5645683OtherNCPDP