Provider Demographics
NPI:1831100429
Name:FOUNTAIN VALLEY CENTRAL PHARMACY INC
Entity Type:Organization
Organization Name:FOUNTAIN VALLEY CENTRAL PHARMACY INC
Other - Org Name:FOUNTAIN VALLEY CENTRAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-839-5115
Mailing Address - Street 1:11055 WARNER AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4007
Mailing Address - Country:US
Mailing Address - Phone:714-839-5115
Mailing Address - Fax:714-839-4656
Practice Address - Street 1:11055 WARNER AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4007
Practice Address - Country:US
Practice Address - Phone:714-839-5115
Practice Address - Fax:714-839-4656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY402363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA402360Medicaid
2116214OtherPK
CA1140910001Medicare NSC