Provider Demographics
NPI:1912021213
Name:BUENA VISTA PHARMACY
Entity Type:Organization
Organization Name:BUENA VISTA PHARMACY
Other - Org Name:BUENA VISTA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-583-0058
Mailing Address - Street 1:23679 CALABASAS RD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1502
Mailing Address - Country:US
Mailing Address - Phone:800-583-0058
Mailing Address - Fax:800-921-4811
Practice Address - Street 1:24007 VENTURA BLVD
Practice Address - Street 2:STE 240
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-1458
Practice Address - Country:US
Practice Address - Phone:800-583-0058
Practice Address - Fax:800-921-4811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA473583336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5614436OtherNCPDP PROVIDER IDENTIFICATION NUMBER