Provider Demographics
NPI:1790955987
Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA-UCSD AMBULATORY CARE PHARMACY
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA-UCSD AMBULATORY CARE PHARMACY
Other - Org Name:UCSD IMG CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR UCSD AMCARE PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGNEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:619-543-6194
Mailing Address - Street 1:200 W ARBOR DR
Mailing Address - Street 2:MAIL CODE 8765
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-9001
Mailing Address - Country:US
Mailing Address - Phone:619-543-6194
Mailing Address - Fax:619-543-5829
Practice Address - Street 1:8939 VILLA LA JOLLA DR
Practice Address - Street 2:STE 129
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1732
Practice Address - Country:US
Practice Address - Phone:858-657-2220
Practice Address - Fax:858-657-2228
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIVERSITY OF CALIFORNIA-UCSDMG
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-04
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHE48990333600000X, 3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGZ617AOtherMEDICARE PART B
CA5629499OtherNCPDP
CA6715070003Medicare NSC