Provider Demographics
NPI:1245671684
Name:INTERGALACTIC HEALTHCARE INC
Entity type:Organization
Organization Name:INTERGALACTIC HEALTHCARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-387-8871
Mailing Address - Street 1:15211 VANOWEN ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3606
Mailing Address - Country:US
Mailing Address - Phone:818-387-8871
Mailing Address - Fax:818-387-8793
Practice Address - Street 1:15211 VANOWEN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3606
Practice Address - Country:US
Practice Address - Phone:818-387-8871
Practice Address - Fax:818-387-8793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-15
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1245671684Medicaid
CA59432OtherSTATE BOARD OF PHARMACY