Provider Demographics
NPI:1740214790
Name:MACTOR, INC.
Entity Type:Organization
Organization Name:MACTOR, INC.
Other - Org Name:PROVISION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MITESH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:619-466-3246
Mailing Address - Street 1:11676 TREADWELL DR
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064
Mailing Address - Country:US
Mailing Address - Phone:619-466-3246
Mailing Address - Fax:619-466-4134
Practice Address - Street 1:4428 GLACIER AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3304
Practice Address - Country:US
Practice Address - Phone:619-466-3246
Practice Address - Fax:619-466-4134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA560913336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA466130Medicaid
0534342OtherNCPDP