Provider Demographics
NPI:1699811190
Name:EISENHOWER MEDICAL CENTER
Entity Type:Organization
Organization Name:EISENHOWER MEDICAL CENTER
Other - Org Name:EISENHOWER MED CTR OP PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KONZEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:760-773-1219
Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:KIEWIT BLDG
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-773-1219
Mailing Address - Fax:760-773-1244
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:KIEWIT BLDG
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-773-1219
Practice Address - Fax:760-773-1244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CAPHY355123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0567771OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHY355120Medicaid