Provider Demographics
NPI:1790111235
Name:SAN ANTONIO PHARMACY
Entity Type:Organization
Organization Name:SAN ANTONIO PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HARRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOENIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-985-2811
Mailing Address - Street 1:255 E BONITA AVE
Mailing Address - Street 2:BUILDING 1, SUITE 102
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1923
Mailing Address - Country:US
Mailing Address - Phone:909-962-6430
Mailing Address - Fax:
Practice Address - Street 1:255 E BONITA AVE
Practice Address - Street 2:BUILDING 1, SUITE 102
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1923
Practice Address - Country:US
Practice Address - Phone:909-962-6430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN ANTONIO REGIONAL HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-16
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA515333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy