Provider Demographics
NPI:1942674304
Name:DATE PHARMACY INC
Entity Type:Organization
Organization Name:DATE PHARMACY INC
Other - Org Name:DATE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PRES, AO
Authorized Official - Prefix:
Authorized Official - First Name:AN
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-765-1325
Mailing Address - Street 1:39765 DATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-2005
Mailing Address - Country:US
Mailing Address - Phone:951-696-5400
Mailing Address - Fax:951-696-5411
Practice Address - Street 1:39765 DATE ST STE 101
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-2005
Practice Address - Country:US
Practice Address - Phone:951-696-5400
Practice Address - Fax:951-696-5411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-23
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY537833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155256OtherPK