Provider Demographics
NPI:1740239623
Name:CORAM HEALTHCARE CORPORATION OF SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:CORAM HEALTHCARE CORPORATION OF SOUTHERN CALIFORNIA
Other - Org Name:CORAM CVS/SPECIALTY INFUSION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:WEINERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-765-1500
Mailing Address - Street 1:PO BOX 809160
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-9160
Mailing Address - Country:US
Mailing Address - Phone:303-672-8631
Mailing Address - Fax:303-298-0047
Practice Address - Street 1:4355 E LOWELL ST
Practice Address - Street 2:STE C
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-2225
Practice Address - Country:US
Practice Address - Phone:909-605-0010
Practice Address - Fax:906-605-5771
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORAM HEALTHCARE CORPORATION OF SOUTHERN CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-09
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2400748251E00000X, 251F00000X
CA261QI0500X
CAPHY49297332B00000X
CAPHY 40884332BP3500X, 333600000X, 3336C0003X, 3336H0001X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No251E00000XAgenciesHome Health
No251F00000XAgenciesHome Infusion
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA 408840Medicaid
0553708OtherNCPDP
CA2400748OtherHOME HEALTH AGENCY
CAPHY49297OtherPHARMACY LICENSE
BC4508579OtherDEA
CA0563500003Medicare NSC
CA0563500003Medicare NSC