Provider Demographics
NPI:1942348958
Name:CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
Entity Type:Organization
Organization Name:CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
Other - Org Name:KLOTZ STUDENT HEALTH CENTER PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR, STUDENT HEALTH CENTER
Authorized Official - Prefix:DR
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:REID
Authorized Official - Last Name:CHASSIAKOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-677-3666
Mailing Address - Street 1:18111 NORDHOFF ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91330-8270
Mailing Address - Country:US
Mailing Address - Phone:818-677-3671
Mailing Address - Fax:818-677-7732
Practice Address - Street 1:18111 NORDHOFF ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91330-8270
Practice Address - Country:US
Practice Address - Phone:818-677-3666
Practice Address - Fax:818-677-7732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHE195853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHE195850Medicaid