Provider Demographics
NPI:1205811601
Name:CREDENA HEALTH LLC
Entity type:Organization
Organization Name:CREDENA HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AVP/SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SKAFI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-650-3396
Mailing Address - Street 1:PO BOX 2704
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1140 W LA VETA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4225
Practice Address - Country:US
Practice Address - Phone:714-744-8724
Practice Address - Fax:714-744-8676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-08
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA380330Medicaid
CA0531067OtherNABP
CA0714400002Medicare NSC