Provider Demographics
NPI:1972525566
Name:FULFILLING HEALTHCARE SERVICES LLC
Entity Type:Organization
Organization Name:FULFILLING HEALTHCARE SERVICES LLC
Other - Org Name:PARKVIEW PHARMACY AND HOME HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:909-981-0956
Mailing Address - Street 1:PO BOX 572227
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-2227
Mailing Address - Country:US
Mailing Address - Phone:909-981-0956
Mailing Address - Fax:909-981-8409
Practice Address - Street 1:8283 GROVE AVE
Practice Address - Street 2:STE 105
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3137
Practice Address - Country:US
Practice Address - Phone:909-981-0956
Practice Address - Fax:909-981-8409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336C0004X
CAPHY472103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1990970OtherPK
CAPHA47210Medicaid
5486250001Medicare NSC
5486250001Medicare NSC