Provider Demographics
NPI:1942220439
Name:PAIN MANAGEMENT PHARMACY INC
Entity Type:Organization
Organization Name:PAIN MANAGEMENT PHARMACY INC
Other - Org Name:PAIN MANAGEMENT PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO VP
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GUESS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:805-928-4700
Mailing Address - Street 1:2003 S MILLER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-7849
Mailing Address - Country:US
Mailing Address - Phone:805-928-4700
Mailing Address - Fax:805-928-4710
Practice Address - Street 1:2003 S MILLER ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-7849
Practice Address - Country:US
Practice Address - Phone:805-928-4700
Practice Address - Fax:805-928-4710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
CAPHY466563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA466560Medicaid
5612848OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA466560Medicaid