Provider Demographics
NPI:1982854956
Name:PACIFIC PHARMACY GROUP
Entity Type:Organization
Organization Name:PACIFIC PHARMACY GROUP
Other - Org Name:ORANGE PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-764-6580
Mailing Address - Street 1:351 HOSPITAL RD STE 211
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 W LA VETA AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4301
Practice Address - Country:US
Practice Address - Phone:714-550-9798
Practice Address - Fax:714-550-9336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-25
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5634274OtherNCPDP
CA1982854956Medicaid
CA6044550004Medicare NSC