Provider Demographics
NPI:1922451905
Name:WEST COVINA MEDICAL CENTER INC
Entity Type:Organization
Organization Name:WEST COVINA MEDICAL CENTER INC
Other - Org Name:WEST COVINA MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-502-1991
Mailing Address - Street 1:725 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2614
Mailing Address - Country:US
Mailing Address - Phone:626-502-1991
Mailing Address - Fax:626-502-1971
Practice Address - Street 1:725 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2614
Practice Address - Country:US
Practice Address - Phone:626-502-1991
Practice Address - Fax:626-502-1971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336I0012X
CA536433336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160697OtherPK