Provider Demographics
NPI:1942200902
Name:CHULAVISTA PHARMACY LLC
Entity Type:Organization
Organization Name:CHULAVISTA PHARMACY LLC
Other - Org Name:CHULAVISTA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/TECH
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:A
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-781-8177
Mailing Address - Street 1:384 H ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5513
Mailing Address - Country:US
Mailing Address - Phone:619-781-8177
Mailing Address - Fax:619-623-3435
Practice Address - Street 1:384 H ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5513
Practice Address - Country:US
Practice Address - Phone:619-781-8177
Practice Address - Fax:619-623-3435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY554093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1942200902OtherMEDI-CAL PROVIDER
2004678OtherPK
CA05-79435OtherNCPDP NUMBER
CAPHY55409OtherCA BOARD OF PHARMACY PERMIT