Provider Demographics
NPI:1861504797
Name:ELEVATE PHARMACY INC
Entity Type:Organization
Organization Name:ELEVATE PHARMACY INC
Other - Org Name:986 PHARMACY #8018
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-843-7200
Mailing Address - Street 1:12370 HESPERIA RD.
Mailing Address - Street 2:#7
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7719
Mailing Address - Country:US
Mailing Address - Phone:760-843-7200
Mailing Address - Fax:760-843-7360
Practice Address - Street 1:12370 HESPERIA RD.
Practice Address - Street 2:#7
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7719
Practice Address - Country:US
Practice Address - Phone:760-843-7200
Practice Address - Fax:760-843-7360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
CAPHY504253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861504797Medicaid
CA1861504797Medicaid