Provider Demographics
NPI:1821359548
Name:YOUR DRUG STORE
Entity Type:Organization
Organization Name:YOUR DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:HUYNH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-949-9310
Mailing Address - Street 1:17079 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-6071
Mailing Address - Country:US
Mailing Address - Phone:760-949-9310
Mailing Address - Fax:760-949-9622
Practice Address - Street 1:17079 MAIN ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-6071
Practice Address - Country:US
Practice Address - Phone:760-949-9310
Practice Address - Fax:760-949-9622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY468363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1336232768Medicaid