Provider Demographics
NPI:1790806602
Name:MARVICH ENTERPRISES, LLC
Entity Type:Organization
Organization Name:MARVICH ENTERPRISES, LLC
Other - Org Name:HIDDEN VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARAVICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:707-900-1524
Mailing Address - Street 1:19851 HARTMANN ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:HIDDEN VALLEY LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95467
Mailing Address - Country:US
Mailing Address - Phone:707-987-3995
Mailing Address - Fax:707-987-3120
Practice Address - Street 1:19851 HARTMANN ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:HIDDEN VALLEY LAKE
Practice Address - State:CA
Practice Address - Zip Code:95467
Practice Address - Country:US
Practice Address - Phone:707-987-3995
Practice Address - Fax:707-987-3120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY456803336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY45680OtherSTATE PHCY LICENSE
CAPHA456800Medicaid